Frances Cappuccini
27 Jan 2017 · Coroner Roger Hatch · Kent (North-West)
The coroner's concerns
1. retained placenta after caesarean section
“What action is taken to check and ensure no part of the placenta remains following a caesarean section delivery?”
2. postpartum haemorrhage management failure
“The protocol for the management of post partum haemorrhage was not followed by the medical staff. What procedures have been instigated to avoid this happening again.”
3. inadequate supervision of anaesthetists
“Supervision - What action has been taken to ensure that staff grade anaesthetists are supervised and that both the staff grade and supervisor are provided details of the respective identities of the parties involved”
4. delayed urgent help request for intensivist/anaesthetist
“What steps have been taken to avoid there being delays in a request for urgent help for an intensivist/anaesthetist”
5. inadequate note keeping
“The Inquest showed a number of examples of inadequate note keeping at the hospital - what actions have been taken to ensure this is not repeated in the future.”
Responses
2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust.pdf ↗· Maidstone and Tunbridge Wells NHS Trust
Stated action
“The standard practice for checking full removal of the placenta during a caesarean section delivery is as follows: The Obstetrician performing the caesarean section inspects the uterine cavity and swabs it out prior to closure. The Midwife inspects the placenta itself once removed - noting its appearance in the healthcare records - and determines if it looks intact. Each placenta is different in terms of shape and size, which makes this a challenging task, but if the Midwife has any concerns regarding”