Xander Curran-Pass

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; A review by an obstetrician did not take place on admission despite RFM and delayed IOL. The trust guidance did not require such a review: Such a review may have identified growing concern about condition of Xander;
5.Xander had his fundal height measured by tape measure by midwives in the community_ There was a significant discrepancy between the recorded measurements of two different midwives, which altered where he was on the centile chart significantly; very

6. Xander's mother was given pethidine. There was no guidance on issues to be considered in terms of advisability of pethidine where there was already significant reduced fetal movement;
7. The quality of documentation on admission was poor;
8. The triage and IOL were poorly kept and used in different ways by staff. The trust has since changed the way records are kept to ensure consistency and improved its audit process. It is unclear if nationally there is clarity on the way in which IOLs are diarised, prioritised and managed;
9. The CTG at 07.09 was concerning from the early stages but the evidence suggested that it was not closely observed;
10. The second CTG after IOL commenced was not reviewed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you have the power to take action: YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 18t September 2019. |, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.