Ivy Morris
2 Nov 2016 · Coroner John Ellery · Shropshire, Telford and Wrekin
The coroner's concerns
1. lack of fetal heart rate monitoring
“[name redacted]'s foetal heart rate ought to have been monitored and was not monitored”
2. failure to assess CTG traces
“To confirm assessment of the CTG using the agreed assessment tool”
3. delayed obstetric review
“The need to request an obstetric review after 1 hour of active pushing”
4. failure to address maternal tachycardia
“The need to request an obstetric review for maternal tachycardia”
5. potential episiotomy delay
“Infiltration took place which could have led to an episiotomy and delivery within 10 minutes”
Responses
No published response was found on judiciary.uk.