“That babies at relative increased risk of early neonatal collapse due to deliveries…”
Dated 8 Apr 2022, from the coroner for Inner 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
Deadline passedReplies were due by 3 Jun 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 dated8 Apr 2022
- Deadline3 Jun 2022
- Published on judiciary.uk26 Apr 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| London North West University Healthcare NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 3 Jun 2022. A reply may have been sent and not yet published. |
The coroner’s concerns
That babies at relative increased risk of early neonatal collapse due to deliveries complicated by factors such as assisted delivery, meconium staining, or early resuscitation assistance, are discharged back to the postnatal ward with no enhanced monitoring of their breathing, heart rate or oxygen saturations, unless they require admission to PICU or neonatal wards. In short that there is no “middle ground” which may allow early detection of collapse and thus increased chance of successful resuscitation should collapse occur.
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, 2022-0107
- 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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