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recurance

Serena Nicholas

14 Nov 2019 · Coroner Kevin McLoughlin · West Yorkshire (East)

The coroner's concerns

  1. 1. disjointed management of high risk pregnancy

    “The antenatal surveillance was largely carried out in Hull where the mother lived. She was seen by a variety of clinicians and at a late stage by a community midwife, despite the recognition that this was a pregnancy accompanied by clear risk factors. The absence of identified consultants responsible for the oversight of mother and baby's care in relation to diabetic and gynaecological aspects resulted in disjointed management.”
  2. 2. unheeded fetal inactivity before C-section

    “The tertiary centre where the C-section (and the subsequent open heart surgery envisaged) were to take place, were not aware that the baby had been inactive for some days before the planned C-section (because the mother had not reported this and had not had contact with clinicians since the clinical appointment with a community midwife on 24/08/1 7). In consequence, a serious adverse development went unheeded until stumbled across on the eve of the C- section. In view of the history of the”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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