Rafe Angelo
27 Nov 2017 · Coroner Karen Harold · Portsmouth & South East Hampshire
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. growth restriction detection
“The risk assessment of Ms [name redacted] followed NICE guidelines at the time but | remain concerned that no simple weight check is done to check maternal BMI and that GROW charts only pick up 50-55% of cases where growth restriction occurs”
2. absence of CTG monitoring
“CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if it is not possible to transport the mother to hospital”
3. unclear transfer urgency classification
“The SIRI investigation highlighted that the instruction given to the maternity support worker was not clear about what category of transfer was required”
4. vague standby points policy
“Consider where the "Use of Standby Points" policy needs to be refreshed to make it clearer and more consistent”
5. inadequate CTG signal quality
“Poor technical quality of the CTG readings at a crucial time especially given "this was the first trace in am emergency situation”
6. unrecorded transfer requests
“Recording all requests to transfer to hospital in notes and active | consideration by midwives”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Poor technical quality of the CTG readings at a crucial time especially given "this was the first trace in am emergency situation”
Later report
“CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery.”
Closely relatedConfidence 0.80 · moderate
This report
“CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if it is not possible to transport the mother to hospital.”
Later report
“During the inquest it was accepted that CTG monitoring should have | taken place at admission given that the pregnancy had been identified as high risk.”
Responses
2017-0421-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action · April 2019
“the HSIB will investigate around 1,000 cases a year with the expectation that the learning from investigations will spur system improvements leading to fewer deaths and injuries in the future.”
2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust.pdf ↗· South Central Ambulance Service NHS Trust