Mia Gibson
11 May 2016 · Coroner Heidi Connor · Nottinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of monitoring of fetal condition
“It appears that great reliance was placed on the fact that was not in pain and had normal observations. Little consideration appears to have been given to the 'second patient' ([the deceased]), whose condition could not be monitored by paramedics. We heard evidence that in fact not all placental abruptions cause the mother significant pain, or concerning observations, but for the baby, it can be akin to a cardiac arrest. This factor appears to have been overlooked in the trust's subsequent investigation”
2. lack of alternative crew availability
“No 'open mic' report was put out to see if other crews could make themselves available to attend this emergency”
3. uncoordinated meal break scheduling
“Dispatchers appear to have allowed a situation to arise whereby the only 2 DCAs not attending other jobs were both on compulsory meal breaks and therefore unavailable at the same time”
4. inadequate obstetric emergency planning
“It was suggested that obstetric emergencies such as placental abruption could”
5. delayed critical care arrival
“No DCA was available to attend this emergency until 30 minutes after the call, and it took a further 12 minutes for a DCA to arrive after that”
6. prolonged handover delay
“The time between the 999 call and being handed over to maternity staff was an hour and 15 minutes”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“This is a clear training issue, and may well apply nationally.”
Later report
“absence of any mandatory training on obstetric emergencies was putting lives at risk.”
Responses
No published response was found on judiciary.uk.