“(brief summary of matters of concern) During the course of the inquest the evidence…”
Dated 18 Mar 2022, from the coroner for Cheshire. 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
Deadline passedReplies were due by 13 May 2022. 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 dated18 Mar 2022
- Deadline13 May 2022
- Published on judiciary.uk22 Mar 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Mid Cheshire Hospitals NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 13 May 2022. A reply may have been sent and not yet published. |
The coroner’s concerns
(brief summary of matters of concern) During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) That the resuscitation area was separate to the operating theatre thus hampering effective communications between the obstetric team and the neonatal team. (2) Neonatal bloods and adult bloods are not kept in the resuscitation room. Since Baby Remi’s death bloods have been moved to the labour ward which is 2 mins away but in time critical moments this may still be too far away.
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, 2022-0085
- 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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