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Coroner’s reportPrevention of future deaths · 2013-0245

“During the inquest | heard evidence of a cut off weight for babies to go into a…”

Dated 27 Sep 2013, from the coroner for Avon. Sent to 1 organisation or person.

A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.

Read the full report on judiciary.uk

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The 56-day response deadline

All responses published

Replies were due by 22 Nov 2013.

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.

  1. Report dated27 Sep 2013
  2. Deadline22 Nov 2013
  3. Published on judiciary.uk27 Sep 2013
  4. Today23 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
Bristol NHS Foundation TrustNamed in the report as “University Hospitals Bristol NHS Foundation Trust”Response publishedPublished on judiciary.uk in September 2013.

Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.

The coroner’s concerns

This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.

—- During the inquest | heard evidence of a cut off weight for babies to go into a transitional area where they will receive more careful monitoring Currently the guideline is babies weighing over 2.5kg do not need to go into this rl a Consultant Neonatologist from the hospital gave evidence about this and indicated that there should be different weights for gestation and different guides for boys and girls. He also said that the presentation of the evidence would be better if it was graphically done and that by referring to a graph it would give a better understanding of a baby being at risk to the staff. In addition IE said that there was a need to synthesize joint working with doctors and midwives. That there should be educational packages for hypoglycaemia and for recognising an unwell baby for both doctors and midwives with a measurement of competency. 6 | ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 22" November 2013 |, the coroner, may extend the period.

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, 2013-0245
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

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