“The conduct of the Trust Serious Incident Investigation – there are outstanding concerns…”

The coroner’s concerns

– 1. The conduct of the Trust Serious Incident Investigation – there are outstanding concerns regarding the methodology, findings and conclusions in this case. The Investigation in my view was flawed in a number of serious ways as follows: • It was undertaken without including, nor giving due weight to, the family evidence, in the analysis and conclusions of the report It was undertaken without any immediate written accounts taken of what had happened, and very limited and delayed interviews of key staff involved The Trust commissioned an expert to assist with the Investigation. This was provided by a well respected Royal College of Obstetrics and Gynaecology recommended expert, and was then ignored, simply because there were aspects of the expert report that the Trust did not accept. All of these omissions in the Investigation process, led to serious omissions in the analysis, conclusions, recommendations and actions that followed in the report, in my view. Also, the Trust, on the evidence of Dr , Executive Medical Director, likely did not share with either the CCG or the CQC, the fact that they had received a detailed, but critical, expert report, that they had not included, nor referred to in the final Investigation report. At the Hearing, there was no reflection on this latter issue by senior Trust staff, no acceptance that the inadequacies of the report had caused huge distress to the family, and more importantly insufficient learning. If there is insufficient learning from a tragic and avoidable death such as this, what reassurance is there that there will be sufficient learning by the Trust in the future. In my mind this poses a continuing risk of similar deaths occurring in the future if the Investigation process does not change. 2. Insufficient support for newly appointed Obstetric Consultants. The Obstetric Consultant who was on call when Jade died, was newly appointed. She was dealing with an extremely complex and challenging situation, yet did not call for help at an early point, when Jade had had a prolonged cardiac arrest, following the uterine inversion. Whilst I accept that it is unrealistic to expect there to be a second Consultant on call every night or weekend to provide additional support, there does need to be a robust system of mentoring, and access to a senior consultant for prompt advice out of hours for at least one year post consultant appointment, and beyond, when serious emergencies such as this arise.

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, 2022-0228

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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