“HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel…”
Dated 29 Sep 2015, from the coroner for Milton Keynes. 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 24 Nov 2015.
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 dated29 Sep 2015
- Deadline24 Nov 2015
- Published on judiciary.uk29 Sep 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Milton Keynes University Hospital NHS Foundation TrustNamed in the report as “Milton Keynes Hospital” | Response publishedPublished on judiciary.uk in September 2015. |
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
– HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel 01908 254326 | Fax 01908 253636 (1)That the most junior member of staff (midwife) was left to look after even though the CTG trace was deemed abnormal. The midwife felt unsupported. (2) Two further members of staff reviewed the CTG trace and yet it appears that no one was in a position of leadership to require a doctor to attend and review the trace and (3)When the consultant on call was requested to attend he indicated that he would do so later. No one on the unit had the leadership role to insist upon his attendance. (4) No one on duty in the unit was able to assume the leadership role and be in a position to offer advice, support and to direct the course of events. (5) There appeared to be a lack of understanding by members of staff as to labour ward management because of the lack of effective leadership. (6) There still appears to be a hierarchical approach to escalation of care within the unit. HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel 01908 254326 | Fax 01908 253636
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, 2015-0393
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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