“During the course of the evidence I was informed that the clinicians consider that there…”
Dated 18 Mar 2025, from the coroner for West Sussex, Brighton and Hove. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 13 May 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated18 Mar 2025
- Deadline13 May 2025
- Published on judiciary.uk26 Mar 2025
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Royal College of Obstetricians and Gynaecologists | Response publishedPublished on judiciary.uk in March 2025. |
| National Institute for Health and Care Excellence | Response publishedPublished on judiciary.uk in March 2025. |
The coroner’s concerns
– During the course of the evidence I was informed that the clinicians consider that there is insufficient guidance as to the management actions that should be taken in the event of an abnormal antenatal CTG. In particular, the clinicians indicated that there was no guidance where there has been an abnormal CTG antenatally as to whether delivery should occur and, if so, in what period. As such, the decision making is reliant on individual clinical judgment.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0152
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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