Archie Hexall

5 Mar 2015 · Coroner Philip Barlow · London (Inner South)

The coroner's concerns

1. respiratory distress in newborn
“About 25 minutes after his birth [the deceased] was noted to be grunting and he then developed nasal flaring, both of which are potential signs of respiratory distress”
2. lack of parental awareness of respiratory concerns
“No-one informed [the deceased]'s ts of the concerns about [the deceased]'s breathing. After”
3. loss of observation records
“the piece of paper on which the observations were recorded was not.retained”