Xander Curran-Pass

1. 1. inadequate staffing or resources

   “The inquest was told that there was a growing challenge to maternity units from the rise in Induction of Labour and the pressure to ensure that timescales set out in NICE guidance were met”

2. 2. lack of clear guidance for prolonged reduced fetal movement

   “The guidance references individual episodes of RFM but does not give clear guidance on the approach to be | taken where in effect there is one prolonged episode rather than multiple episodes of RFM”

3. 3. failure to advise mother to return for monitoring

   “[the deceased]'s mother was not told it would be advisable to return to triage for further monitoring in light of the ongoing reduced foetal movement”

4. 4. absence of obstetric review on admission

   “A review by an obstetrician did not take place on admission despite RFM and delayed IOL”

5. 5. inconsistent measurement technique

   “[the deceased] had his fundal height measured by tape measure by midwives in the community”

6. 6. inappropriate medication administration

   “[the deceased]'s mother was given pethidine”

No published response was found on judiciary.uk.