“During the inquest it became clear that during the telephone conversation between EMAS…”
Dated 1 Mar 2018, from the coroner for Manchester South. Sent to 4 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
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 8 Jun 2018, after the 56 days for replies had ended (26 Apr 2018). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated1 Mar 2018
- Deadline26 Apr 2018
- Published on judiciary.uk8 Jun 2018
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Stepping Hill Hospital | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 8 Jun 2018, after the 56 days for replies had ended (26 Apr 2018). These dates can’t tell us whether a reply was due before it went online. |
| East Midlands Ambulance Service NHS TrustNamed in the report as “East Midlands Ambulance Service” | Response publishedPublished on judiciary.uk in June 2018. |
| Health Services Safety Investigations BodyNamed in the report as “Healthcare Safety Investigation Branch” | Response publishedPublished on judiciary.uk in June 2018. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in June 2018. |
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
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
—- 1. During the inquest it became clear that during the telephone conversation between EMAS and George’s mother her labour was rapidly developing. There was no evidence of the call taker seeking guidance on how to deal with a rapidly evolving situation other than to update the ambulance crew who were on route.(EMAS) 2. The way in which information was exchanged between Stepping Hill Hospital and EMAS meant that all those involved in making decisions were not in possession of key facts. There was no structure to how information was shared and it was passed 3 hand. 3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought.
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, 2018-0062
- 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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