Jos Tartese-Joy
31 Dec 2021 · Coroner Alison Mutch · Greater Manchester South
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of flagging high risk pregnancy
“no nationally recognised way of flagging this within the notes”
2. no induction plan for high risk pregnancy
“no plan for an induction of labour in place”
3. separate floors for triage and delivery
“layout of maternity services at the trust meant that triage and delivery were on different floors”
4. lack of admission CTG monitoring for high risk pregnancy
“CTG monitoring should have | taken place at admission”
5. unclear escalation process for trainee midwife
“lack of clarity regarding the escalation process she needed to follow”
6. misinterpretation of centile chart guidance
“guidance nationally was not to look at this but to look at the % weight _ change”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if it is not possible to transport the mother to hospital.”
This report
“During the inquest it was accepted that CTG monitoring should have | taken place at admission given that the pregnancy had been identified as high risk.”
Closely relatedConfidence 0.80 · moderate
This report
“guidance nationally was not to look at this but to look at the % weight _ change between the last weight and the new weight.”
Later report
“tracking weight on the centile chart even from an early point assisted in understanding if there was a significant issue in relation to feeding triggering professional curiosity.”
Responses
2021-0435-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action · 2023/24
“I note that it was found that there was no nationally recognised way of flagging in maternity notes that a pregnancy is considered high-risk. As a consequence, the community midwife and GP were not aware that the pregnancy was high-risk, and additionally the mother herself was not explicitly counselled about this.”