Malyun Karama
21 Aug 2020 · Coroner M E Hassell · Inner North London
The coroner's concerns
1. excessive misoprostol dose
“following a diagnosis of intrauterine death. The misoprostol was administered at doses in excess of the Royal College of Obstetricians and Gynaecologists national guidelines.”
2. lack of recording equipment
“there was no computer in the delivery suite and so she could not record her observations contemporaneously or without leaving the room”
3. lack of mandatory medical review
“changing the misoprostol dose protocol and making a medical review mandatory before each administration to a multi gravida mother”
Responses
2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf ↗· Royal Free Hospital
Stated action · 2 October 2020
“Learning in relation to the increased risk of rupture in relation to multigravida women to be shared with the national maternity risk/governance managers email distribution forum. This was completed on 2 October 2020 and the email that was distributed has been embedded into the attached action plan.”
Stated action · 2 September 2020
“Ensure a computer is in the delivery suite to enable contemporaneous note-keeping Please refer to the attached action plan item 2 and document, which can be summarised as follows: The Action required is for a review to take place of the workstations on wheels (WOW) on the Labour Ward to ensure that all Labour rooms possess a computer for staff use. This review was completed on 2 September 2020 and it identified that there were the appropriate number of workstation on wheels for the Labour rooms.”
Stated action
“Log an incident on our Datix system to ensure the issue is investigated.”