Nola-Reign Morgan
24 Jun 2026 · Coroner Martin Lanchester · Gwent
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of national guidance for antenatal fetal monitoring in chorioamnionitis
“National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between [the deceased]'s mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.”
2. new local guidance omits chorioamnionitis and monitoring considerations
“Health Board Antenatal Fetal Monitoring Guidance. Following Nola- Reign's death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring”
3. insufficient training evidence for staff
“Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since [the deceased]'s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:”
4. unnecessary delay in critical transfer
“Delay in transferring between Antenatal and HDU wards. The delay in transferring [the deceased]'s mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola- Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Whilst Pennine Acute Hospitals NHS Trust has now established its own local guidelines based upon recent research conducted in Bristol, there are no national guidelines on how to interpret and/or classify antenatal (as opposed to intra-partum) CTG tracings.”
This report
“National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected.”
Closely relatedConfidence 0.85 · high
Earlier report
“He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.”
This report
“Delay in transferring between Antenatal and HDU wards. The delay in transferring [the deceased]'s mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised.”
Responses
No published response was found on judiciary.uk.