Jade Hart

“The conduct of the Trust Serious Incident Investigation - there are outstanding concerns regarding the methodology, findings and conclusions in this case. The Investigation in my view was flawed in a number of serious ways as follows: - It was undertaken without including, nor giving due weight to, the family evidence, in the analysis and conclusions of the report - It was undertaken without any immediate written accounts taken of what had happened, and very limited and delayed interviews of key”

“Insufficient support for newly appointed Obstetric Consultants. The Obstetric Consultant who was on call when [the deceased] died, was newly appointed. She was dealing with an extremely complex and challenging situation, yet did not call for help at an early point, when [the deceased] had had a prolonged cardiac arrest, following the uterine inversion. Whilst I accept that it is unrealistic to expect there to be a second Consultant on call every night or weekend to provide additional support, there does need to be”