“The failure to supervise the operating surgeon on her first day at work for this complex…”

The coroner’s concerns

– (I) The failure to supervise the operating surgeon on her first day at work for this complex twin delivery. It was stated in evidence that the policy of inducting new staff had changed but that this had not been enshrined in any formal document. Such a document should be produced and a copy submitted to myself. 2 (II) The lack of any steps having been taken to discipline the clinicians involved or limit their practice given their decision to adopt a wholly inappropriate, unacceptable, and unorthodox technique in delivering Thor, resulting in his death. (III) The failure to ensure a full contemporaneous record was kept by doctors involved in a term neonatal death. Such failure has seriously hampered my investigation into the circumstances surrounding Thor's death and has resulted in serious difficulties to Thor's family who clearly struggled and suffered as a result of not being able to understand why their son died shortly after his birth. (IV) The failure to identify in the immediate aftermath of Thor's death that the operating surgeons had neglected to make a full note of the circumstances in which he died and to obligate them to provide the same; in particular was advised to amend the Caesarean pro forma, to include the fact that forceps were used in the interests of candour. He was then dissuaded from doing so by senior management as a result of their concerns as to how this would be perceived if the matter was investigated. This raises very serious concerns as to the degree of candour in disclosing the circumstances of this death. What steps have been taken to obviate a repetition of this behaviour in the future? (V) The fact that the consultant ultimately responsible for Thor was also charged with undertaking the SUI Report into his death. Further, that the consultant signed off the original SUI Report without having read any of the statements referred to in that report. Please disclose the policy or means by which it has been made clear that this should not happen in the future. (VI) The fact that the original SUI and the revised version completed after receipt of the post mortem failed to disclose that there was no support for the use of forceps to disimpact the fetal head. (VII) The fact that no steps have been taken to discipline those involved in the production of this wholly inadequate SUI. (VIII) The fact that none of the statements served by the Trust disclosed that there was no support for the use of forceps to disimpact the fetal head. (IX) 6. The fact that there was a failure to recognise the inadequacy of the operating surgeon's original statement and SUI and that these inadequacies were not addressed until I directed the Trust to obtain a full statement and undertake a comprehensive SUI.

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, 2015-0063

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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