Source · Prevention of Future Deaths
Elouise Winship
Ref: 2014-0431
Date: 7 Oct 2014
Coroner: John Gittins
Area: North Wales (East & Central)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified the absence of a documented regime for regular fetal heart auscultation after opiate administration to mothers. There were also concerns that further examinations and observations were not consistently undertaken following a change in the mother's condition.
Date
7 Oct 2014
56-day deadline
2 Dec 2014
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner identified the absence of a documented regime for regular fetal heart auscultation after opiate administration to mothers. There were also concerns that further examinations and observations were not consistently undertaken following a change in the mother's condition.
View full coroner's concerns
That although a Local Serious Review was undertaken following Elouise's death in which it was agreed that the fefal heart should have been auscultated on a regular basis following administration of opiates to the mother, there is no documented regime by which this has been adopted into standard practice_ That it should be considered a good practice (which should if possible be incorporated into_the care pathway that there should be a further examination of being mothers with fresh observations being undertaken following a recognisable change in the mother's condition; regardless of the phase or anticipated progress of the labour.
Report sections
Investigation and inquest
On the 21st of March 2011 commenced an investigation into the death of Elouise Winship (DOB 11.3.11, DOD 12.3.11). The investigation concluded at the end of the inquest on the 3r of October 2014 and recorded a conclusion of a death from natural causes, the cause of death being 1(a) Massive Aspiration of Amniotic Fluid and Meconium due to 1(b) Severe Intrauterinelintrapartal Asphyxia due to 1(c) Umbilical Cord Wrapped around the Baby:
Circumstances of the death
The Circumstances of the death are that Elouise was resuscitated after delivered unresponsive on the 11 of March 2011 but failed to survive beyond thirteen hours.
Action should be taken
In my opinion action should be taken t0 prevent future deaths and believe your organisations have the power to take such action.
Similar PFD reports
Report details
- Reference
- 2014-0431
- Date of report
- 7 October 2014
- Coroner
- John Gittins
- Coroner area
- North Wales (East & Central)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Dec 2014 (stated in the report).
Sent to
- Betsi Cadwaladr University Health Board