“The Inquest was held one year after Bethan Naomi Harris's death”
Dated 22 Jun 2020, from the coroner for West London. 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 publishedOrganisations 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 dated22 Jun 2020
- Deadline17 Aug 2020
- Published on judiciary.uk14 Sep 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| St George's University Hospitals NHS Foundation TrustNamed in the report as “St. George’s University Hospitals NHS Foundation Trust” | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
(1) The Inquest was held one year after Bethan Naomi Harris's death. During the course of the oral evidence it emerged that several, in my mind important, learning issues had not been addressed. (2) There were issues relating to handover of patients to midwives and at the time of Inquest there had been no further specific training in relation to handover. Indeed it was stated that the process in place at the time of Bethan's delivery still pertained without alteration. This represented a risk to patients. (3) At the time of Inquest a team debrief, which I consider to be a source of learning to reduce the risk of serious incident in future was still outstanding. (4) There was little evidence from the oral evidence given that any effective reflection, reflective discussions or learning had taken place subsequent to Bethan's birth and then death. I consider it important that organisations seek to ensure individual and collective reflection to seek to avoid repetition. The evidence for this, one year on, was lacking. 3
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, 2020-0133
- Added to Minute Book
- 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
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