“ARE: 1”
Dated 19 May 2023, from the coroner for Cambridgeshire and Peterborough. 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 publishedReplies were due by 14 Jul 2023.
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; a reply may have been sent and not yet published.
- Report dated19 May 2023
- Deadline14 Jul 2023
- Published on judiciary.uk23 May 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North West Anglia NHS Foundation Trust | Response publishedPublished on judiciary.uk in May 2023. |
The coroner’s concerns
ARE: 1. While I heard evidence that there has been training for Midwives on how to take cord blood, and I was provided with a copy of a poster that was said to have been in use at the Trust for some time, in April 2023, over 2 years after this delivery, the Midwife gave evidence that she and her colleagues were of the opinion that it was appropriate to take a sample from anywhere in the cord, not just in the clamped area. The expert and the Trust’s own Head of Midwifery advised that this was not appropriate. It therefore does not appear that the learning has been passed on to all Trust Midwives and there is a risk that in future cases those treating the baby will be falsely reassured by normal cord pH results which may not be accurate. 2. While I read evidence of some training that had been provided in response to HSIB recommendations for further training on auscultation in addition to saturation monitoring and ECG monitoring during resuscitation, the independent expert also recommended training on UVC and IO access. I am also concerned that there does not appear to have been training in relation to the provision of blood transfusions in such cases to ensure that all potential reversible causes are treated before resuscitation stops. The Head of Midwifery who attended the inquest to advise on issues relating to the recommendations was not in a position to provide evidence on the neonatal position and I have been provided with no evidence by the Trust that these issues have been considered. I am concerned that they require further action.
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, 2023-0167
- Added to Minute Book
- 7 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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