A) I received evidence that on the facts of this case, the latest time that Mrs Bailey could have arrived at hospital with any realistic prospect of survival was 19.40 hours. Ultimately the decision to take her to Boston Pilgrim hospital was futile, although that was not known at the time.

B) I also received evidence that two pre-alert calls were made by the travelling paramedics to Boston Pilgrim Hospital to advise of the serious nature of Mrs Bailey's condition, those calls being made at approximately 20.30 hours and at 20.42 hours. C) I received evidence from Mr Bailey that upon arrival at hospital the clinicians appeared not to be ready for his wife's arrival.

D) I received evidence from Mr , consultant in the Accident and Emergency Unit at Boston Pilgrim Hospital, that , a Specialty Doctor in Emergency medicine present at the time had noted in the medical records that he, together with other doctors had attempted to resuscitate Mrs Bailey who had presented to A & E in a collapsed state around 21.00 hours and had noted that " a cardiac arrest call-out had also been initiated in or around the time of the patient's arrival to Pilgrim."

E) I received evidence from the locum registrar for the labour ward, that "[My understanding at that time was that] no Obstetrician and gynaecologist was forewarned about this patients arrival to the A & E department."

F) The ED records confirmed that two pre alert calls were recorded but not dated nor signed.

G) Whilst the severity of Mrs Bailey's condition meant that in the particular circumstances of this case the treatment Mrs Bailey received at hospital neither caused nor contributed to her death, the apparent breakdown in communication does raise an area of concern in relation to future emergency admissions.