Lana-Liza Chervonenko

1. 1. delayed medical review of pathological CTG trace

   “was very busy on the night of 7/8"" March 2014. The levels of activity on the ward resulted in the following: ¢ A delay in obtaining a medical review to the concerning CTG trace. * A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace”

2. 2. incorrect caesarean section grading documentation

   “Incorrect documentation in relation to the grading of the caesarean section”

3. 3. lack of communication with anaesthetist

   “The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients”

4. 4. absence of proactive theatre availability notification system

   “there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available”

5. 5. missed opportunity for timely delivery

   “Had been taken to theatre at 00.22, the consultant has confirmed that lana-Liza would have been delivered by 00.40”

6. 6. lack of theatre availability notification system

   “also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available”

No published response was found on judiciary.uk.