Langley, Archer

Contributing factors

• Delayed recognition of obstructed labour at 15:15
• Delayed progression to caesarean section (85 minutes from decision; 3 hours from when decision should have been made)
• Absence of consultant from birth suite during critical period
• Communication breakdown between midwifery and junior medical staff
• Junior doctor (Dr D.) reviewed CTG in isolation without full patient assessment
• Failed handoff of critical clinical findings (caput, moulding, blood-stained urine) to senior registrar
• Senior registrar (Dr S.) unaware of key clinical signs when making management decisions
• CTG abnormalities noted but not escalated to urgent action despite abnormal decelerations from 16:48 onwards
• High workload in birth suite on the day limiting consultant availability
• Poor documentation of clinical concerns in medical notes despite clear midwifery concerns

Coroner's recommendations

1. Clarify documentation processes regarding completion of partogram versus progress notes to avoid confusion about where clinical findings should be recorded and ensure findings are visible to reviewing clinicians
2. Reinforce RCA recommendations with staff through continued training and mandatory audits on implementation
3. Provide bereavement facilities including a suitable room and dedicated bereavement team for families experiencing perinatal death