This film highlights the importance of creating an open and transparent culture where staff feel able to speak up will help Trusts to identify problematic practise before significant issues arise.
This film highlights the culture and power dynamics in this fictional maternity unit, which are demonstrated by tension between the midwife and doctor and the impact that this had on the care in this case.
As detailed in the Ockenden Report, Trusts must have clear standard operating pathways on when and how to escalate but there also needs to be a culture whereby staff feel able to escalate their concerns and understand that they will be listened to. This is not just about escalation from midwife to obstetrician, but also registrar to consultant. Creating an open and transparent culture where staff feel able to speak up will help Trusts to identify problematic practise before significant issues arise.
The film also emphasises the importance of organisational learning evidence at inquest to provide the Coroner with assurance so that the statutory duty to issue a Report to Prevent Future Deaths is not triggered. If an organisation can demonstrate learning from the death and evidence that action has been taken to prevent future harm in advance of an inquest this may avoid a PFD Report. However, as highlighted in the Chief Coroner’s updated guidance, PFD reports are not intended as a punishment – they are a learning tool, issued for the benefit of the public.
On Saturday 15 October a wave of light swept the internet when thousands of people flooded social media with pictures of candles to remember the babies that they have lost. This event signifies the end of Baby Loss Awareness Week which aims to break the silence that is associated with baby loss in pregnancy and infancy.
HSIB published its report on Maternal deaths during the first wave of COVID-19. The report takes a closer look at the impact that COVID-19 had during the initial period of March to May 2020.
The much anticipated final Ockenden report was published on 30 March 2020. The final report sets out the findings of the review into care provided to 1,486 families, and sets out a blueprint for safe maternity care.
Consent is often a key issue in obstetric claims and if it is relevant to the facts of the death, its likely to be an area explored by a coroner.
This video illustrates some of the issues that can arise when a witness is poorly prepared.
This film highlights the importance of creating an open and transparent culture where staff feel able to speak up will help Trusts to identify problematic practise before significant issues arise.
Lockdown restrictions in March 2020 led to many inquest hearings being postponed. As restrictions eased, Coroners came under increasing pressure to reduce the number of delayed inquest hearings. In June 2020, the Chief Coroner issued Guidance No. 38 to facilitate remote participation in coroner’s inquests.
