Kobi Wright
16 Jul 2020 · Coroner Jacqueline Lake · Norfolk
The coroner's concerns
1. cervix dilation misassessment
“evidence was that the cervix was almost fully dilated at 12:30 and 13:50 examinations at which point it could be "pushed easily”
2. failure to act on abnormal CTG
“Dr evidence was that during a telephone conversation at 13:57 he did not express concern about the CTG reading and did not give this as the reason to proceed to delivery of [the deceased]”
3. inadequate risk communication
“Dr evidence at the inquest that he expressed concern about [the deceased]'s mother being pre- term, high risk with prolonged rupture of membranes was not contained in his first statement nor in his record of the conversation”
4. misinterpretation of CTG variability
“Further second statement 21.4.2020, refers to some consideration being given to variable decelerations and variabilities contained in the CTG trace when making his decision to proceed to delivery”
5. inadequate clinical assessment
“Dr gave evidence that his arranging to take [the deceased]'s mother to theatre and prepare for delivery, and then carrying out a further vaginal examination at that time, would stand in for a later examination to see how matters were progressing”
6. refusal of senior assistance
“Dr did not accept the Consultant's offer of assistance but regarded himself as fully competent to carry out the procedure”