“| The two trusts involved gave evidence of detailed action plans to address locally…”

The coroner’s concerns

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- | The two trusts involved gave evidence of detailed action plans to address locally issues identified. However the inquest identified issues that it was | clear could be found outside the two trusts where action has been taken. 1. A feature of the evidence was lack of communication between the teams of midwives and social worker. This meant that it was not picked up that his mother had missed a key fetal growth scan and that a small baby was not monitored for the period between 10" September until his birth on 24" September. The inquest heard that contributing to this was a shortage of midwives in the enhanced midwifery team and a shortage of experienced social workers in the Local Authority at the time; 2. Caspian’s family had been identified as vulnerable. There was a lack of clarity about how to effectively support and manage the the pregnancy and during delivery; 3. There had been two undocumented calls to triage on the morning of 24" September 2018. The inquest heard that that when staff were busy on the triage team calls and advice were not always documented; 4. Decision making that was not in accordance with trust guidance on 10'" September was not clearly documented in the notes; 5. The 1% CTG on 24" September was a pathological CTG from the very early stages but was not reviewed until half an hour had | elapsed despite the history. An expectation that CTG should be observed for a period of time after first starting would have allowed for earlier identification of fetal distress; 6. Early signs of sepsis were not identified by the consultant neonatologist because it was thought the observations reflected a move to warming from cooling. The other experienced staff within the NICU did not appear to recognise a deteriorating position until 12 hours after early signs of deterioration were noted. | situation to ensure that there was effective engagement throughout | | |

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, 2019-0305

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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