Laura-Jane Seaman
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. absence of contemporaneous Labour Ward medication chart
“The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward”
2. significant omissions in medical record-keeping and incorrect medication chart entry
“Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023”
3. vital signs recorded on cardiotocograph paper instead of MEOWS charts
“Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts”
4. communication failures and information sharing problems
“Communication issues with Trust staff and sharing of information”
5. non-compliance with national guidance and training
“Lack of compliance with national guidance and training”
6. absence of contemporaneous blood testing for high-risk postpartum hemorrhage patient
“Absence of contemporaneous blood testing results for [the deceased] as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient”
Linked reports
This report
“Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023”
Later report
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation”
This report
“d. Communication issues with Trust staff and sharing of information”
Later report
“I am concerned that the documentation and communication failures identified in this case may not be confined to a single ward, clinical team or hospital site.”
Responses
2024-0688-Response-from-Mid-South-Essex-NHS-Trust.pdf ↗· Mid and South Essex NHS Foundation Trust
Stated action · 2025
“All Mid and South Essex Hospital NHS Foundation Trust ('MSE') sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record.”
2024-0688-Response-from-Royal-College-of-Obstetricians-and-Gynaecologists.pdf ↗· Royal College of Obstetricians and Gynaecology for Clinical Quality