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Trust Failings Identified in Coroner’s Summing Up

After hearing two and half days of evidence at the inquest of Joshua Titcombe, HM Coroner Ian Smith identified ten failings at Furness General Hospital.

After hearing two and half days of evidence, HM Coroner Ian Smith’s verdict was, “Joshua Titcombe died of natural causes following a number of missed opportunities to identify that he was ill and to provide him with appropriate treatment.”

In his summing up, Mr Smith identified ten failings at Furness General Hospital. These were:

  1. Failure to listen to and understand the family’s concerns;
  2. Failure to record fully or at all many of the factors which, taken together, might have led to a greater degree of suspicion or a referral to a paediatrician; Failure by some staff still to recognise that the standard of record keeping was unacceptable;
  3. Failure to understand a basic medical fact that a low temperature  or a failure to maintain a temperature could be a sign of infection in a neonate;
  4. Failure to monitor the signs of infection in Joshua;
  5. Absence of continuity of care before and during the birth;
  6. The treatment of the protocol on Prolonged Rupture of the Membranes as a rigid formula and not as a tool to make a considered diagnosis and (if necessary) to get a doctor to attend;
  7. Mrs Titcombe and Joshua were treated as unrelated individuals. No thought was given to how, if something was affecting Hoa, it might also affect Joshua. Failure to think of them laterally and holistically as a mother and baby.
  8. Failure by all staff to acknowledge that  the midwives were working as a separate team and that there was no integration between the midwifery and paediatric teams;
  9. Failure to identify that the unit was short staffed on that day;
  10. Inadequate, or no, training for midwives on the post-natal ward to carry out the observations that the SCBU nurses had done.

Further details on the inquest can be found at: http://www.burnetts.co.uk/publications/news/missed-opportunities-led-to-babys-death

For further media information contact Angela Huck on 07525 128762 or email ash@burnetts.co.uk

Published: Thursday 8th September 2011
Categorised: Medical Negligence

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