“Notwithstanding the presence at all material times of a Consultant on the delivery ward…”
Dated 30 Jun 2014, from the coroner for Leicester City and South Leicestershire. 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.
The 56-day response deadline
All responses publishedReplies were due by 25 Aug 2014.
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 dated30 Jun 2014
- Deadline25 Aug 2014
- Published on judiciary.uk30 Jun 2014
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of Leicester NHS Trust | Response publishedPublished on judiciary.uk in June 2014. |
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.
— (1) Notwithstanding the presence at all material times of a Consultant on the delivery ward, the length of time of the second stage of this labour did not appear to be communicated effectively to either the Consultant or the midwife co-ordinator, due to other events occurring that night. The “white board” system of communication was ineffective as neither of the above had an opportunity to look at this. The Trust should consider a proforma for communication on such occasions that is effective and may include sight of the CTG trace, where applicable, by the most senior clinician available. (2)The Trust escalation policy has been changed since this death, but there seemed to be uncertainly.on how well this was known by all relevant midwifery and medical staff, and in particular ensuring knowledge for new staff. Knowledge of the procedures, and adherence to the time limits set out for escalation are key to the effectiveness and the Trust should consider further how this can be robustly incorporated into working practice. (3) The Trust should consider arranging for additional midwifery and medical availability to assist during times of extreme demand on the service. The current informal “SOS” system for midwifery attendance, while promising, should be further explored and confirmed in Trust policy if considered to be effective.
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, 2014-0287
- 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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