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Sienna Monterio

16 Sept 2023 · Coroner Alan Wilson · Blackpool & Fylde
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The coroner's concerns

  1. 1. blood gas analyser not set to analyse haemoglobin

    “Paired cord blood gas samples were taken at the time of birth of the Baby. The blood gas analyser was not set to analyse the haemoglobin. This prevented other possible causes for the Baby's condition being considered and possibly corrected.”

  2. 2. absence of Hb measurement in neonatal resuscitation settings

    “The Trust to ensure a blood gas analyser with an Hb (haemoglobin) measurement facility is available in all neonatal resuscitation settings to support the provision of clinical information, and to optimise decision making processes and clinical care.”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Sienna Monterio · Recurance