George French-Russell
1 Mar 2018 · Coroner Alison Mutch · Manchester (South)
The coroner's concerns
1. lack of guidance for rapidly evolving labour
“during the telephone conversation between EMAS and [the deceased]'s mother her labour was rapidly developing. There was no evidence of the call taker seeking guidance on how to deal with a rapidly evolving situation other than to update the ambulance crew who were on route.”
2. lack of structured information exchange
“The way in which information was exchanged between Stepping Hill Hospital and EMAS meant that all those involved in making decisions were not in possession of key facts. There was no structure to how information was shared and it was passed 3 hand”
3. inexperienced paramedics handling footling breech delivery
“During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought”
Responses
2018-0062-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
2018-0062-Response-by-East-Midlands-Ambulance-Service-NHS-Trust.pdf ↗· East Midlands Ambulance Service
Stated action · May 2018
“The EMAS emergency operations centre (EOC) has in place a structured triage and escalation system to ensure that patient safety is embedded across the call handling and dispatch systems.”
2018-0062-Response-by-HSIB.pdf ↗· Department of Health and Social Care