Louisa Walker (1)

27 Oct 2025 · Coroner Heidi Connor · Berkshire

The coroner's concerns

1. impacted fetal head
“by way of green top guideline or otherwise) dealing with impacted fetal head seen at caesarean section. 2”
2. uncertainty and absence of relevant training
“risk of uncertainty and absence of relevant training in respect of this obstetric emergency”
3. increasing incidence of impacted fetal head
“impacted fetal head is becoming increasingly common”

Stated action

“We will continue to review emerging evidence and consider guideline development when the evidence base permits”