Evelyn Rae Le Masurier-O'Sullivan

“The NICE Guideline (2021) Postnatal Care (NG194) recommends that at each postnatal contact, a parent or carer should be asked if they have any concerns about the baby's wellbeing, feeding or development; and that the history should be reviewed and the baby's health reviewed including by physical observation.”

“If there are early indicators of possible infection in a baby, including respiratory distress, then immediate clinical assessment should be performed, the maternal and neonatal history should be reviewed and a physical examination of the baby should be carried out.”

“In [name redacted]'s case, I concluded that: although [name redacted]'s mother was seen by a member of the midwifery team at postnatal contacts at around 00:30 and by a midwife at around 02:30, they did not elicit concerns [name redacted]'s parents had about [name redacted]'s crying and breathing, and nor did they afford an opportunity for these concerns to be shared; and this led to an absence of neonatal assessments being carried out and absence of escalation to the hospital's neonatal team, which contributed to the death.”

“all temporary staffing supplied at Croydon University Hospital including midwives is provided by "On-Framework" suppliers under framework RM6281 (RM6281 is a framework agreement managed under the NHS Workforce Alliance for the procurement of clinical and healthcare staffing across the UK); and (ii) most NHS Trusts, including Croydon Health Services NHS Trust, do not provide in-house training to their agency staff as they are not provided with funding for them to be trained”