“The Serious Incident Report prepared on behalf of East and North Hertfordshire NHS Trust…”
Dated 15 Dec 2020, from the coroner for Hertfordshire. Sent to 2 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
Deadline passedReplies were due by 9 Feb 2021. A reply may have been sent and not yet published.
Organisations 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.
- Report dated15 Dec 2020
- Deadline9 Feb 2021
- Published on judiciary.uk7 Jan 2021
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East and North Hertfordshire Teaching NHS TrustNamed in the report as “East and North Hertfordshire NHS Trust” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Department of Health and Social Care | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
(1) The Serious Incident Report prepared on behalf of East and North Hertfordshire NHS Trust concluded that the Investigation was unable to determine the factors that were directly responsible for the death of baby Eddie Coffey. This conclusion was directly contradicted by evidence at the inquest. (2) Evidence was given at the inquest by a Consultant Obstetrician from Lister Hospital that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey might have survived. 1 (3) Evidence was given at the inquest by an independent Consultant Obstetrician that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey would more than likely have survived. (4) It was not clear from the inquest that, despite training implemented by the Trust since the death, that the same situation would not arise again. (5) The Evidence was given at the inquest by an independent Consultant Obstetrician that 100 maternity units in the country are following the wrong guidelines in relation to managing foetal heart rate monitoring in labour.
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, 2020-0287
- 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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