“Evidence emerged during the inquest that the Paediatric Doctor in charge recognised that…”
Dated 28 Jun 2016, from the coroner for Black Country. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Dates unclearOrganisations 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.
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- Report dated28 Jun 2016
- Published on judiciary.uk8 Jun 2016
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Responses from each recipient
| Sent to | Response |
|---|---|
| Walsall Healthcare NHS Trust | Response publishedPublished on judiciary.uk in June 2016. |
| Care Quality Commission | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
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The coroner’s concerns
– 1. Evidence emerged during the inquest that the Paediatric Doctor in charge recognised that it was a mistake to extubate baby when he did. His words were: “What should have been a straight forward ET change turned into a nightmare”. He also confirmed that he should have consulted the Consultant on call prior to making the decision and earlier use of the CO2 monitor would have made a difference. 2 2. In addition, it emerged that there were problems and delays in trying to contact the tertiary unit via the switchboard. 3. There was also evidence of an inadequate handover and preparation for the arrival of the premature baby with insufficient care plan details or consultation taking place.
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, 2016-0241
- 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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