“The maternity and neonatal departments undertook an investigation into Etta’s mother’s…”

The coroner’s concerns

– The maternity and neonatal departments undertook an investigation into Etta’s mother’s care antenatally and after Etta’s delivery. The concerns are as follows:a. The neonatal investigation was not thorough. The investigator did not obtain or request statements from doctors directly involved in Etta’s resuscitation, nor did they meet with them to understand what had occurred. The investigation was based on records alone. The records themselves, identified as part of the investigation, were often incomplete or included retrospective entries. Despite this, the investigator nor the panel involved considered speaking to or obtaining statements from crucial individuals. Coroner's Office, Shirehall Street, Caernarfon b. There was no sufficiently full contextual sharing of the investigation or its findings from a neonatal or maternity perspective. Some witnesses had only received and read the report several weeks prior to the Inquest. c. The memoranda sent to staff highlighting the learning did not include context or narrative around the circumstances of investigation. Therefore, those not directly involved would not have been fully aware of the context of what had occurred. Having issued Reports to the Health Board regarding quality of investigation previously, this concern remains. Specifically, I have concerns that the neonatal element of the investigation was not thorough enough such that without this genuine learning and change will not and cannot occur. Even where learning has been shared, I am concerned that this is not contextualised sufficiently. I am also concerned that staff not involved in the incident will not learn fully enough from events where there is inadequate sharing of learning from an incident.

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, 2025-0236

Added to Minute Book

8 Oct 2026

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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