“Regulation 28 – After Inquest Document Template Updated 30/07/2021 1”
Dated 26 Feb 2024, from the coroner for West Sussex, Brighton and Hove. 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 22 Apr 2024.
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 dated26 Feb 2024
- Deadline22 Apr 2024
- Published on judiciary.uk28 Feb 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals Sussex NHS Foundation TrustNamed in the report as “University Hospitals Sussex NHS Foundation” | Response publishedPublished on judiciary.uk in February 2024. |
The coroner’s concerns
Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. Alissa Claire Norton was born on 18 April 2022 at 39 + 5 weeks gestation at Worthing Hospital. At the time of and after Alissa’s birth there were two midwives present as per Trust Policy. One midwife was primarily looking after Mrs Norton and the other her daughter Alissa. 2. The evidence that I heard was that the majority of the notes which were adduced in evidence as to the events and treatment of Alissa were completed retrospectively on the next day (19 April 2022) by the midwife who cared for Mrs Norton. There were very limited notes completed by the midwife caring for Alissa at the time or at any time thereafter. 3. Therefore, there was limited documented information available to treating clinicians following Alissa’s birth as to the events and treatment which had been provided to her. 4. The inquest heard that some of the notes completed retrospectively were based on assumption rather than first hand knowledge. This was not clear in the notes.
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, 2024-0108
- Added to Minute Book
- 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
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