It was clear at the inquest that maternity services which had been commissioned in this region had not been required to have a specification for record keeping, notes and scans which could be digitally available to other maternity services operating in the same area. Such that Arrowe Park Hospital needed to have the paper notes from One to One North West Ltd. to ensure continuity of care.

This does not appear to be the most efficient system for continuity of patient care and could have been remedied by the commissioners of the services requiring compatible record keeping and medical note systems to ensure the easy sharing of information.

This would also enable community based midwives to refer a patient to a consultant without the patient necessarily having to attend the maternity unit in the first place.

Further access to notes would make the admission to the maternity unit safer and seamless, delivering what should be a better patient experience and outcome.