Source · Prevention of Future Deaths
Amy Cooper
Ref: 2016-0072
Date: 25 Feb 2016
Coroner: Andre Rebello
Area: Liverpool and Wirral
Responses identified: 0 / 2
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Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and referrals.
Date
25 Feb 2016
56-day deadline
22 Apr 2016
Responses identified
0 of 2
Coroner's concerns
Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and referrals.
View full coroner's concerns
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.
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.
Report sections
Investigation and inquest
On 15th July 2015 I commenced an investigation into the death of Amy Rose COOPER , Aged 153 minutes.
The investigation concluded at the end of the inquest on 25th February 2016. The cause of death was: a Intrauterine growth restriction b Antepartum asphyxia c Maternal vascular underperfusion in the placenta in addition to fetal thrombotic vasculopathy, umbilical vasculitis and acute subchorionitis and low grade villitis of unknown aetiology
The conclusion was: Natural Causes
The investigation concluded at the end of the inquest on 25th February 2016. The cause of death was: a Intrauterine growth restriction b Antepartum asphyxia c Maternal vascular underperfusion in the placenta in addition to fetal thrombotic vasculopathy, umbilical vasculitis and acute subchorionitis and low grade villitis of unknown aetiology
The conclusion was: Natural Causes
Circumstances of the death
On the 8th July 2015 at 20.12 Amy was born at 40 weeks gestation by caesarean section at Arrowe Park Hospital, Wirral. Amy was in a poorly state and required immediate resuscitation. At 20.47 (35 minutes of life) it was determined that resuscitation would not be successful and Amy was confirmed as having died at 22.55. It was not evident to community midwives or the hospital maternity unit that Amy had intrauterine growth restriction until after post-mortem investigations.
Amy and her mother had been under the care of one to one midwives (North West) Limited – St James Children Centre, 334 Laird Street, Birkenhead CH41 7AL which is a community midwifery service. The Maternity where Amy was born at Arrowe Park Hospital which is part of the Wirral University Teaching Hospital Foundation Trust.
Amy and her mother had been under the care of one to one midwives (North West) Limited – St James Children Centre, 334 Laird Street, Birkenhead CH41 7AL which is a community midwifery service. The Maternity where Amy was born at Arrowe Park Hospital which is part of the Wirral University Teaching Hospital Foundation Trust.
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Report details
- Reference
- 2016-0072
- Date of report
- 25 February 2016
- Coroner
- Andre Rebello
- Coroner area
- Liverpool and Wirral
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Apr 2016.
Sent to
- Department for Health
- NHS England