“Ante natal checks carried out to detect SGA babies The risk assessment of Ms Angelo…”

The coroner’s concerns

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4. Ante natal checks carried out to detect SGA babies The risk assessment of Ms Angelo followed NICE guidelines at the time but | remain concerned that no simple weight check is done to check maternal BMI and that GROW charts only pick up 50-55% of cases where growth restriction occurs. A ‘more holistic view is needed of risk factors especially in last few weeks from 34 weeks onwards as this is when the major growth spurt takes place and monitoring closely when additional factors surface is advisable e.g. as in this case cannabis and anti-depressant use were disclosed during this crucial period. (33; 36; 37; 97; 117; 125; 167; 168] | 2. Guidance needed post a bradycardic episode in labour After the bradycardic episode at 11:10 when the maternal position was changed, the recovery rate afterwards was higher than the previous baseline from 130-135 to 150+ thereafter. This was still within “normal” range but it was accepted during the inquest that this could be abnormal and no guidance currently exists. . [118; 127; 128; 172] 3. Availability and use of CTG at birthing centres CTG is not currently available in birthing centres and should be considered in emergency situations such as this case especially if itis not possible to transport the mother to hospital. 10. [54, 98, 115-116, 118, 121, 123, 134, 169-170, 182-183, 186, 200] Clarification of what would be classified as urgent/non-urgent or an emergency in the transfer policy The SIRI investigation highlighted that the instruction given to the maternity support worker was not clear about what category of transfer was required. That is why the maternity service has purchased cordless handsets so that the midwife giving clinical care can contact SCAS directly rather than delegate the task t is now made in the birthing room so the mother can hear. In aeeeey indicated that a transfer for epidural would be regarded as an emergency requiring an ambulance within one hour. This was different (rom who feit the transfer would be classified as non-urgent. A discussion took place in court as SCAS representatives believed the response time was 30 minutes (para 151). This needs to be clarified between the Trust and SCAS and then clearly communicated to all staff. Discretion of SCAS call handlers if time critical factors are mentioned but birthing centre staff do not actually request a time critical transfer is requested. (74-76, 132, 190, 191, 194] Consider where the “Use of Standby Points” policy needs to be refreshed to make it clearer and more consistent The call to SCAS from the Blake lasted 4 minutes, 57 seconds and the fact the baby was in distress was not mentioned until 3 minutes, 53 seconds. The responding ambulance was despatched at 15:46 and shortly afterwards the paramedic contacted control centre and indicated that it was appreciated the call was an emergency but could acilities first. No questions were asked and permission was —_ | pe that if this had been designated as a time critical call, it may have made a difference as to whether permission to use facilities would have been given and asking questions or not would depend on the person taking the call from the paramedic. There was a policy to cover this sort of request — “Use of Standby Points” but it was accepted the policy is very broad and somewhat vague so it was accepted that it would very much depend on the person taking the call to probe further [74] Guidance for midwives about auscultation practice during transfer to hospital (14, 48, 57, 115, 120} Ensuring an account is created for ail staff authorised to use CTG equipment so that settings and prints can be run [49, 65, 174] Poor technical quality of the CTG readings at a crucial time especially given this was the first trace in am emergency situation (66, 116, 123, 175] Recording all requests to transfer to hospital in notes and active consideration by midwives Although it was found that the notes in this case were very good, nevertheless there was a finding that the mother had made several requests to go to hospital mainly for pain relief during the course of the morning and early afternoon yet none of these requests were recorded in the notes or acknowledged by the midwife. In this case, it was agreed by several witnesses includin a that if an earlier transfer had happened this would have led to CTG monitoring and picking up the earlier declerations. (23-26, 30-31, 45, 53, 58, 177-183} 11. System of relaying information from birthing centre staff to hospital staff in an emergency situation This was a critical part of this case and as such needs further consideration of both the past and current systems and whether appropriate training has been given; whether it is currently working; and whether refresher training is needed. (119, 123, 131, 195-202]

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, 2017-0421

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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