Rhianne Barton

1 Jun 2016 · Coroner Karen Henderson · Surrey

The coroner's concerns

1. lack of obstetric consultant supervision
“[the deceased]'s named obstetric consultant was not informed of her emergency admission”
2. failure to exclude surgical cause
“No consideration was given to excluding a surgical cause of [the deceased]'s symptoms despite the history of sudden onset of upper abdominal pain in the knowledge that she had had bariatric surgery”
3. delayed investigations
“there was still a responsibility to exclude other causes of abdominal pain in the absence of an obstetric cause, by undertaking appropriate investigations in a timely fashion”
4. inadequate documentation
“poor documentation of routine observations and an incomplete fluid balance chart”
5. lack of obstetric care plan
“The obstetric consultant made no specific plans with regard to the obstetric care that [the deceased] would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery”
6. guidance gap
“Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians”