Tommi-Ray Vigrass
28 Jun 2016 · Coroner Zafar Siddique · Black Country
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. extubation of premature baby
“What should have been a straight forward ET change turned into a nightmare”
2. delayed communication with tertiary unit
“problems and delays in trying to contact the tertiary unit via the switchboard”
3. inadequate handover and preparation
“evidence of an inadequate handover and preparation for the arrival of the premature baby with insufficient care plan details or consultation”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care.”
This report
“There was also evidence of an inadequate handover and preparation for the arrival of the premature baby with insufficient care plan details or consultation taking place.”
Responses
2016-0241-Response-by-Walsall-Healthcare-NHS-Trust.pdf ↗· Walsall Healthcare NHS Trust
Stated action
“Neonatal staff have now undergone training on 'Difficult Airway Management' This includes the use of Oropharyngeal airways Nasopharyngeal airways Laryngeal mask airway (LMA) CO2 detector Introducer [name redacted] blade Video laryngoscope”