Jenson Francis
17 May 2019 · Coroner David Regan · South Wales Central
The coroner's concerns
1. dysfunctional team without clear leader
“The root cause analysis characterises the presence of a "dysfunctional team without a clear leader”
2. poor CTG interpretation
“There was a poor standard of CTG interpretation, with insufficient training and review”
3. unclear communication about caesarean section category
“There was unclear communication as to whether a category | or 2 caesarean section was required”
4. incomplete NEWS charts and partograms
“NEWS charts and partograms were not completed, and there was a poor standard of record keeping”
5. insufficient staffing and lack of consultant attendance
“There were insufficient staffing levels, and very high acuity, despite which there was no consultant attendance and the escalation policy was not used”