Zachary Taylor-Smith
14 Mar 2024 · Coroner Susan Evans · Derby and Derbyshire
The coroner's concerns
1. lack of understanding of four hour post-birth deterioration indicators
“Staff lacking appreciation and proper understanding of the significance of the four hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period”
2. lack of awareness of membrane rupture timing in preterm births
“Staff lacking appreciation of the significance of the timing between rupture of membranes in a pre-term birth and birth and therefore failing to note or ask to be furnished with that information to inform their assessment of the risks of infection in babies”
3. persistent cultural issues between maternity and neonatal teams
“The persisting cultural issues affecting the relationships and communication between maternity and neonatal staff. Given that the responsibility for checking and monitoring signs of infection in the newborn was not, from the evidence, placed on either the midwifery team or the neonatologists but was a joint one, the relationship that exists between the teams is of critical importance”
4. absence of system to maintain active review status
“Absence of an effective system in place to ensure required reviews remain live until completed”
5. lack of formal safety review for planned inductions
“Absence of a formal mechanism for reviewing whether it is safe for planned inductions to take place in the context of ward and neonatal units levels of activity and capacity”