“The clinical care provided to Sam in the obstetric department was not escalated…”
Dated 21 Oct 2015, from the coroner for Gloucestershire. 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
Deadline passedReplies were due by 16 Dec 2015. A reply may have been sent and not yet published.
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.
- Report dated21 Oct 2015
- Deadline16 Dec 2015
- Published on judiciary.uk21 Oct 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Gloucestershire Hospitals NHS Foundation TrustNamed in the report as “Gloucestershire Hospitals NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Dec 2015. A reply may have been sent and not yet published. |
The coroner’s concerns
– (1) The clinical care provided to Sam in the obstetric department was not escalated appropriately to more senior colleagues, (2) When Sam was being cared for in the community, there was no process to ensure the sharing of information or joining up of care between the midwives, out of hours, GP and obstetric department. (3) When Sam attended the Emergency Department as a post-natal patient (7 days post partum) the obstetric department were not involved in her care.
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, 2015-0413
- 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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