Elton Deutekom

“That Chelsea and Westminster Hospital are not appropriately referring neonatal deaths to coroner- either late or not at all, and this raises the possibly that lessons may not be learned from the investigation of these deaths that may save the lives of others.”

“That Chelsea and Westminster hospital may not be complying with the duty of candour to disclose evidence relevant to a death to the coroner until forced to by court directions made in public, which thus raises the same concern as above.”

“That following neonatal deaths assistance is given to midwifery staff as to how to write records in retrospect and contemporaneous handwritten notes are destroyed possibly reducing the accuracy of the records and thus risking that lessons may not be learned that may save the lives of others.”

“That the labour ward is understaffed.”

“That newly qualified midwives should have more supervision whilst they are managing women in labour.”

“That there is no regular review system for CTGs on the central CTG monitoring board.”