Leanne Carroll
19 Mar 2025 · Coroner Kate Robertson · North Wales (East and Central)
The coroner's concerns
1. insufficient awareness of the Service by health professionals
“insufficient awareness of the Service by health professionals including midwives, health visitors and GP's”
2. lack of permanent perinatal health visitors across all three Health Board areas
“only 2 temporary perinatal health visitors across the 3 Health Board areas and not one in the Eastern area”
3. future deaths due to inadequate Service awareness staffing and documentation
“deaths will occur into the future as awareness of the Service is not at all adequate to health professionals, the Service is not adequately staffed and records of meetings and decisions made in the Single Point of Access are not documented”