“(brief summary of matters of concern) 1”

The coroner’s concerns

(brief summary of matters of concern) 1. The Trust’s Antepartum Haemorrhage guideline gives no sense of urgency when staff are faced with a bleed – here, staff failed to appreciate the potential for a sinister cause of bleeding both at 21.18 and later at 03.40, and did not appear to appreciate the fact that a volume of the bleeding may well be occult, by the external volume representing only a small proportion of the actual blood loss. Miss Al-Samarrai accepted that further work was likely to be required in this regard. 2. Failure to ensure early reflective accounts were captured from key staff in response to this significant event and others. I consider this to be a Trust wide issue. The Trust cannot begin to rectify patient safety issues, if they do not understand exactly what has happened and why. This analysis can only properly occur with the input of those involved in care, and in circumstances where those individuals have had the opportunity and support of the Trust to capture early written accounts. The Trust currently has no clear system in place to facilitate this early capture of relevant accounts.

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, 2024-0351

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