Source · Prevention of Future Deaths
Xander Curran-Pass
Ref: 2019-0249
Date: 24 Jul 2019
Coroner: Alison Mutch
Area: Manchester (South)
Responses identified: 0 / 4
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Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and failure to advise a mother to return for further monitoring for ongoing concerns were identified.
Date
24 Jul 2019
56-day deadline
4 Nov 2019 est.
Responses identified
0 of 4
Coroner's concerns
Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and failure to advise a mother to return for further monitoring for ongoing concerns were identified.
View full coroner's concerns
1.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: In this case and since the death of Xander the trust have taken steps to reconfigure their IOL process to reduce risk but no provision to share such learning nationally existed;
2.In the inquest reference was made to the guidance from the Royal College on 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. Xander's mother was not told it would be advisable to retur to triage for further monitoring in light of the ongoing reduced foetal movement: The inquest was told that this would have been advisable given the prolonged nature and the fact that it was unclear when she would be offered a slot for IOL;
2.In the inquest reference was made to the guidance from the Royal College on 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. Xander's mother was not told it would be advisable to retur to triage for further monitoring in light of the ongoing reduced foetal movement: The inquest was told that this would have been advisable given the prolonged nature and the fact that it was unclear when she would be offered a slot for IOL;
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Report details
- Reference
- 2019-0249
- Date of report
- 24 July 2019
- Coroner
- Alison Mutch
- Coroner area
- Manchester (South)
Responses identified
Responses identified
0 of 4
4 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Nov 2019 (estimated).
Sent to
- Department of Health and Social Care
- National Institute for Health and Care Excellence
- Stepping Hill Hospital
- the Healthcare Safety Investigation Branch (HSIB)