Bethan Harris
22 Jun 2020 · Coroner Séan Cummings · West London
The coroner's concerns
1. delayed inquest
“The Inquest was held one year after [the deceased] [name redacted]'s death. During the course of the oral evidence it emerged that several, in my mind important, learning issues had not been addressed.”
2. handover of patients to midwives
“There were issues relating to handover of patients to midwives and at the time of Inquest there had been no further specific training in relation to handover. Indeed it was stated that the process in place at the time of [the deceased]'s delivery still pertained without alteration. This represented a risk to patients.”
3. outstanding team debrief
“At the time of Inquest a team debrief, which I consider to be a source of learning to reduce the risk of serious incident in future was still outstanding.”
4. lack of reflection and learning
“There was little evidence from the oral evidence given that any effective reflection, reflective discussions or learning had taken place subsequent to [the deceased]'s birth and then death. I consider it important that organisations seek to ensure individual and collective reflection to seek to avoid repetition. The evidence for this, one year on, was lacking.”
Responses
2020-0133-Response-from-St.-Georges-University-Hospitals-Trust_Redacted.pdf ↗· St George's University Hospitals NHS Trust
Stated action · October 2020
“the maternity governance team undertakes a quarterly maternity notes audit. This involves auditing the notes of women attending for 40 and 41 weeks antenatal appointment and the information given regarding induction of labour. The last quarterly audit reported 67% of women had induction of labour discussed and offered at 40 weeks and 83% at 41 weeks gestation. Although this percentage is below the expected performance target of 95% at 40 weeks, the maternity governance team is working towards ensuring”