“What action is taken to check and ensure no part of the placenta remains following 2…”
Dated 27 Jan 2017, from the coroner for North West Kent. 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 Mar 2017.
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 dated27 Jan 2017
- Deadline24 Mar 2017
- Published on judiciary.uk19 Feb 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Maidstone and Tunbridge Wells NHS Trust | Response publishedPublished on judiciary.uk in February 2017. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 1. What action is taken to check and ensure no part of the placenta remains following 2 caesarean section delvery? 2. The protocol for the management of post partum haemorrhage was not folowed by the medical staff. What procedures have been instigated to avoid this happening again. 3. Supervision — What action has been taken to ensure that staff grade anaesthetists are supervised and that both the staff grade and supervisor are provided details of the respective identities of the parties involved 4. What steps have been taken to avoid there being delays in a request for urgent help for an intensivist/anaesthetist. 5. The Inquest showed a number of examples of inadequate note keeping at the hospital — what actions have been taken to ensure this is not repeated in the future.
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, 2017-0020
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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