Vasilis Ktorakis
19 Oct 2015 · Coroner ME Hassell · London Inner (North)
The coroner's concerns
1. delayed administration of Syntocinon
“was started on Syntocinon at 7.15pm on Friday, 22 May 2015. Given the circumstances of her presentation (including meconium stained liquor and infrequent contractions at a late stage of labour), her consultant told me in court that when was seen by a registrar at 2.40pm that afternoon, the registrar should have conducted a full review and started Syntocinon then, some four and a half hours before.”
2. inadequate documentation of management plan
“The notes recorded by that registrar fell significantly short of what can be expected in terms of recording a management plan.”
3. excessive passive descent period
“At ten past midnight on Saturday, 23 May, a different registrar took the decision to allow two hours passive descent before pushing.”
4. exclusion from incident investigation
“The first registrar was not asked to contribute to the hospital's untoward incident investigation, so there was a systemic failure to understand the value of her input, resulting in a loss of learning for the organisation and for the registrar.”
5. lack of feedback to registrars
“Neither the first nor the second registrar was notified of the untoward incident investigation findings, even by the time of inquest, and so the opportunity for them to learn and to improve was lost.”
6. absence of robust learning system
“This seems to demonstrate a lack of a robust system for learning lessons.”