Thomas Beaty

31 Mar 2015 · Coroner Lisa Hashmi · Manchester (North)

The coroner's concerns

1. abandoning instrumental delivery too early or too late
“When to abandon the procedure: - No evidence of progressive descent with each pull - No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator...”
2. ambiguous terminology causing misinterpretation
“The RCOG Guidance did not provide operational definitions for words such - as 'imminent' (vis a vis birth) or”
3. misleading term 'gentle' causing unsafe traction
“The term 'gentle' (traction) forming the 'G' of the algorithm within the Trust's - protocol was misleading and not in line with the RCOG Guidance”
4. delayed adoption of improved guidance
“it is difficult for Trusts to change their guidance until - and unless there is a change/material improvement in the Guidance issued by the RCOG”