“(brief summary of matters of concern) I heard evidence that the Trust are committed to…”
Dated 14 Mar 2024, from the coroner for Derby and Derbyshire. 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 9 May 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 dated14 Mar 2024
- Deadline9 May 2024
- Published on judiciary.uk21 Mar 2024
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of Derby and Burton NHS Foundation Trust | Response publishedPublished on judiciary.uk in March 2024. |
The coroner’s concerns
(brief summary of matters of concern) I heard evidence that the Trust are committed to improvement and have already made and are planning to make important improvements. However, I remain concerned in relation to the following matters: a. Staff lacking appreciation and proper understanding of the significance of the four hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period. b. Staff lacking appreciation of the significance of the timing between rupture of membranes in a pre-term birth and birth and therefore failing to note or ask to be furnished with that information to inform their assessment of the risks of infection in babies. c. The persisting cultural issues affecting the relationships and communication between maternity and neonatal staff. Given that the responsibility for checking and monitoring signs of infection in the newborn was not, from the evidence, placed on either the midwifery team or the neonatologists but was a joint one, the relationship that exists between the teams is of critical importance. d. Absence of an effective system in place to ensure required reviews remain live until completed. e. Absence of a formal mechanism for reviewing whether it is safe for planned inductions to take place in the context of ward and neonatal units levels of activity and capacity.
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, 2024-0152
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use