“Independent expert opinion has drawn attention to the following areas of concern • Lack…”
Dated 9 Sep 2020, from the coroner for Essex. 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 dated9 Sep 2020
- Deadline4 Nov 2020
- Published on judiciary.uk16 Nov 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Mid and South Essex NHS Foundation Trust | Response publishedPublished on judiciary.uk in June 2022. |
The coroner’s concerns
– Independent expert opinion has drawn attention to the following areas of concern • Lack of risk assessment leading to the options available to mothers as to delivery • Forceps delivery was attempted without recognising an occipitoposterior position. More training in this respect is required and the use of scans developed. • The injuries imply an excessive degree of force in the application of the forceps and the traction • Concerns about the engagement and induction of locum staff and management of staff levels on the maternity ward • The need for a bleep in the neonatal unit • Accuracy of record keeping • Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre • Training and procedures in respect of how communications with the family should be carried out. This should cover the duty of candour. • Availability and suitability of resuscitation equipment and procedures on the maternity ward. The Trust’s Neonatal Resuscitation Policy may need to be revisited • The Trust’s Action Plan must be rigorously carried out • It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery. Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In March 2019, HM Government issued a Consultation on coronial investigations of stillbirths It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.
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, 2020-0173
- Added to Minute Book
- 8 Oct 2026
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- 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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