Wynter Andrews
9 Oct 2020 · Coroner Laurinda Bower · Nottingham City and Nottinghamshire
The coroner's concerns
1. lack of robust initial critical analysis of deaths
“Lack of robust initial critical analysis of deaths”
2. failure to listen to and respond to staff safety concerns
“Failure to listen to and respond to staff safety concerns”
3. failure to promote and facilitate professional challenge
“Failure to promote and facilitate professional challenge”
4. failure to reach decisions based on individualised patient risk
“Failure to reach decisions based on individualised patient risk”
Responses
2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf ↗· Nottingham University Hospitals NHS Trust
Stated action · 1st February 2021
“Broadening understanding of the Medical Examiner process through more widely engaging maternity and paediatric staff through training and awareness seminars. There will be sharing of expectations of information needed by the Medical Examiner for early and robust collection of relevant details from Neonatologists, Paediatricians, Midwives, Obstetricians and parents/carers/family.”