Frederick Terry
9 Sept 2020 · Coroner Caroline Beasley-Murray · Essex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of risk assessment
“Lack of risk assessment leading to the options available to mothers as to delivery”
2. forceps delivery without occipito-posterior position recognition
“Forceps delivery was attempted without recognising an occipito- posterior position. More training in this respect is required and the use of scans developed”
3. excessive force in forceps application
“The injuries imply an excessive degree of force in the application of the forceps and the traction”
4. locum staff engagement and staffing levels
“Concerns about the engagement and induction of locum staff and management of staff levels on the maternity ward”
5. absence of neonatal bleep system
“The need for a bleep in the neonatal unit”
6. inaccurate record keeping
“Accuracy of record keeping”
Linked reports
Identical hazardConfidence 0.95 · high
This report
“Accuracy of record keeping - Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre”
Later report
“During the course of this investigation I heard evidence of significant deficiencies in the maintenance of clinical records relating to hydration, nutrition, communication, observations, medication management and aspects of clinical decision making.”
Responses
2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf ↗· Mid and South Essex NHS Foundation Trust
Stated action
“The guidelines have been updated to reflect the Royal College of Obstetricians and Gynaecologists recent guideline on Assisted Vaginal Birth (April, 2020)1, this includes a risk assessment to assist with decision making for an assisted vaginal birth, an improved documentation pro forma following an assisted vaginal birth and reference to ensuring that the baby's head is checked immediately at birth for signs of trauma when obstetric instruments have been applied.”