Phoenix Chapman
14 Jul 2023 · Coroner Mary Hassell · Inner North London
The coroner's concerns
1. delayed transport to hospital for unplanned home delivery
“new national maternity guidance is to be published at the end of the month. This will include within it revised advice for paramedics faced with an unplanned home delivery such as this one to transport to hospital even if birth is imminent”
2. lack of midwife input into protocol development
“midwives felt that their views of what should happen in the event of precipitous labour had not been taken seriously”
3. inconsistent clinical protocol understanding
“there was not a shared understanding among the clinicians within the trust about how such a situation should be approached”