Elisa Fuller
17 Oct 2019 · Coroner Katy Skerrett · Gloucestershire
The coroner's concerns
1. lack of escalation support for junior staff
“Whether there is appropriate support and systems in place to encourage Junior Midwives and Junior Doctors to escalate any concerns they have to more Senior Colleagues”
2. insufficient understanding of placenta retention
“Whether there is sufficient understanding of the need to retain placentas post delivery”