1. Lack of robust initial critical analysis of deaths Prior to 1 October 2019, when the Notification of Deaths Regulations 2019 came into force, the Trust were mandated by local agreement to refer every child death (even expected deaths) to HM Coroner.

However, the implementation of the Regulations, removed the discretion of coroners to set local referral criteria. Wynter’s death occurred just two weeks prior to the implementation of the Regulations, and was therefore referred to HM Coroner as ‘standard procedure’.

The referral itself expressed that Wynter’s death was ‘Expected’ and as a result, there had been no review performed by the Rapid Response Clinician for Unexpected Paediatric Deaths.

The checklist on the reverse of the referral to HM Coroner indicated that the only trigger for referral was the “Deceased’s Age”. The boxes for neglect, unnatural death, allegations of negligence, and death associated with a clinical incident were all left unticked.

The detail within the body of the report made no reference to any of the failings that have become apparent throughout the inquest, and indeed, would have been apparent upon robust scrutiny of the CTG trace and medical records available at the time.

The referral explained that the reporting doctor was happy to propose a cause of death, and happy to complete the Medical Certificate of Cause of Death. The effect of this, would have meant Wynter’s death being registered as a natural death and without investigation by the Coroner.

As is usual practice, before the Coroner reaches a decision, the Coroner’s officer makes contact with the family to see if they have any concerns. Understandably, this is a shocking and upsetting time for the family, but they had the clarity of thought at that stage to express some concerns about the events leading up to labour, which were sufficient for the Coroner to direct an independent post mortem examination.

The full picture then unfolded through the coronial investigation and the separate Health Sector Investigation Branch inquiry.

I am concerned that the lack of robust initial critical analysis of deaths has the potential to lead to missed opportunities to learn lessons that are vital to improving patient safety. Mrs agreed that one of the recommendations to come out of this inquest is a review of the current 72-hour table top review of care. This risk goes beyond obstetric deaths and has the ability to prevent learning from deaths within other Divisions of the Trust.

For that reason, I am informing the Trust’s Chief Executive of my concerns through a PFD report.

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2. The unsafe culture prevailing within Midwifery Services

(a) Failure to listen to and respond to staff safety concerns I have made findings that the Maternity Services were operated in an unsafe manner on 14 – 15 September 2019. Staff told me this was not the first time, nor the last time, that they have been asked to care for multiple families simultaneously, meaning that those families cannot receive the time, focus and dedication they require. Staff further told me that they have repeatedly raised their concerns about patient safety, but their concerns have been met with silence. I saw evidence that staff were repeatedly raising their concerns through the Datix system, but they told me they would receive no feedback in reply nor would anything change.

(b) Failure to promote and facilitate professional challenge Midwives spoke of their inability to professionally challenge plans made by medical staff, even in circumstances where they felt the plan might harm mother or baby. The culture failed to promote professional challenge and multi-disciplinary care of women. Decisions were often made in isolation, without understanding the full background and patient wishes.

(c) Failure to reach decisions based on individualised patient risk It was custom and practice that critical decisions, such as which patient to transfer to the labour suite when demand outstripped supply, were made in isolation without reading the patient notes, speaking with the midwife caring for the patient, without seeing the patient, without seeking medical input and, crucially, without assessing individualised patient risk at the point the patient was unable to receive the care on the labour ward that they required.

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