Leilani Chute

15 Jul 2016 · Coroner Bridget Dolan QC · West Sussex

The coroner's concerns

1. manual pushing back of cervix by junior doctors
“the practice of manually pushing back the cervix was one adopted by two junior doctors. This practice was not in accordance with standard training and was conducted without the knowledge of the consultant;”
2. inadequate informed consent for labour management choices
“the manner in which consent was sought from women in labour when there was a choice to be made between attempted instrumental delivery and going straight to a CS did not appear to provide them with the relevant facts in order to come to an informed choice, but presented those facts that favoured the doctot's pteferred approach to management”
3. lack of corrective action for identified safety issues
“neither of the above matters had been identified as a "Care and Service Delivery problem" by the Trust's Root Cause Analysis investigation and hence no steps had been taken by the Trust to address these issues”