Maia Strachan
28 May 2019 · Coroner Karen Dilks · Newcastle Upon Tyne
The coroner's concerns
1. inability to store sequential scan data specific to each patient
“The ability to store sequential scan data specific to each patient and provide alerts to the Sonographer”
2. lack of access to obstetric and diabetic records
“Asystem of joint obstetric and diabetic care operates without the facility for clinicians to access patients' obstetric and diabetic records whether manually or electronically”
3. absence of clear joint decision making policy
“Provision of advice and explanation of the risks of pregnancy and the risks/benefits of vaginal delivery or by Caesarean Section are essential to ensure informed decision making”
4. lack of policy for fetal scalp electrode use
“The use of Foetal Scalp Electrodes (FSE) provide critical information in respect of foetal distress and the time implications thereof”
5. suboptimal documentation
“The Trust should implement a robust training and audit plan to address the risks of this occurring in the future”
6. lack of dissemination of expert findings
“A redacted copy of HE eport and conclusions should be circulated to all obstetrics and gynaecology staff (both nursing and medical) and all midwives”