“About 25 minutes after his birth Archie was noted to be grunting and he then developed…”

The coroner’s concerns

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— (1) About 25 minutes after his birth Archie was noted to be grunting and he then developed nasal flaring, both of which are potential signs of respiratory distress. He was rformed a/Set of observations; including oxygen saturations, and she’also. noticed vorniting, grunting and nasal: flaring! The evidence at thelinquest : | Was that wrote the observations on.a piéce of paper because the medical. ee Tecords were ‘not immediately availa ble (her observations;:were performed shortly after’: |: the birth of, Archie's brother: who téquired resuscitation). Midwife: later transcribed! | midwife iii these results into the medical.records, However, the evidence was that midv was not aware of the vomiting, grunting and nasal flaring potibeg by midwife i: although midwife [EM believes she did pass this information’on verbally... - During this'period attention may understandably have been focugsed on Archie's brother. However; am concerned: that the important'information about further possible - Signs of ‘respiratory distress 'was soriehow, lost:in the communication between'the two Also, the piece of paper on which the observations were recorded was not retained. lam concerned that this should have been retained in the medical records. (2) No-one informed Archie’s {s of the concerns about Archie’s breathing. After returning.to delivety suite a was left alone with Archie for a period of between 7: and 10 minutes. During this period noted that Archie’s breathing was irregular. My finding’at the inquest was that if,he had known of the midwives’ concerns he would have raised the alarm sooner, although it was not possible to say from the evidence whether this would have altered the outcome. | do of course understand ‘that a balance needs to be maintained between sharing relevant information with parents and Causing unnecessary alarm. However sharing relevant information potentially enables parents to make important contributions to their child’s care and my concern is that this opportunity:\was lost in this case.

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, 2015-0081

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