Coroner issues sternest warning to Chelsea & Westminster hospital over baby death

Read more about Elton's case.

Professor Fiona Wilcox, Senior Coroner for Inner West London, said that the hospital is not appropriately referring neonatal deaths to the coroner, meaning lessons may not be learnt from investigating such deaths.

She also warned that the hospital may be failing to comply with its duty of candour to families and their lawyers until forced to do so by the court.

Working with Eli and Tijl, Elton's parents, on both the inquest and an ongoing negligence claim against the hospital, I know how extremely distressing it has been for them having to force the hospital to acknowledge the mistakes that led to Elton's death and ultimately to reveal exactly what went wrong.

This attitude by the trust compounds not only parents' all-consuming grief after losing a baby but also denies them the facts behind the death, leading many clients to feel terrible guilt that they somehow caused their baby's death.

We hear time and again from clients that if any good can come from such a tragedy, it is that other people might not to have to go through similar if medics and managers learn from the mistakes.

To come up against a wall of determination to cover up the reasons a baby died forces families into a battle many are simply not resilient enough to face.

Professor Wilcox also highlighted that the midwife caring for Elton and his mother Eli destroyed her contemporaneous handwritten notes and instead presented to the court a record that she wrote later with the help of another member of staff, calling into question their accuracy.

Below is the full list of concerns included within the Regulation 28 Preventing Future Deaths report. The trust has 56 days to respond.

1. That Chelsea and Westminster Hospital are not appropriately referring neonatal deaths to coroner- either late or not at all, and this raises the possibly that lessons may not be learned from the investigation of these deaths that may save the lives of others.
2. That Chelsea and Westminster hospital may not be complying with the duty of candour to disclose evidence relevant to a death to the coroner until forced to by court directions made in public, which thus raises the same concern as above.
3. That following neonatal deaths assistance is given to midwifery staff as to how to write records in retrospect and contemporaneous handwritten notes are destroyed possibly reducing the accuracy of the records and thus risking that lessons may not be learned that may save the lives of others.
4. That the labour ward is understaffed.
5. That newly qualified midwives should have more supervision whilst they are managing women in labour.
6. That there is no regular review system for CTGs on the central CTG monitoring board.
7. That in some hospitals the Medical Examiners do not have access to obstetric records when reviewing deaths.
8. That the neonatologists at Chelsea and Westminster are not passing sufficient and appropriate information to the pathologists when consented post- mortem examinations occur such that the cause of death found by the pathologist may be inaccurate.
9. That neonatologists in other hospitals may not be appropriately reporting deaths to the coroner.

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