16 Jul 2020 Kobi David WRIGHT · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Failure to carry out a further vaginal examination after an hour before deciding how to proceed with delivery View source Lack of recent emergency obstetrics training View source Rotation of the baby’s head alone during obstructed delivery View source Failure to appropriately interpret CTG readings and the full clinical picture before proceeding to delivery View source Failure to accept consultant assistance during the procedure View source See 2 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kobi David WRIGHT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kobi David WRIGHT was delivered on 3 March 2019 after unsuccessful forceps and caesarean delivery attempts and was declared dead after showing no signs of life. The concerns included conflicting accounts of cervical dilatation and the clinical reasoning for proceeding to delivery, failure to allow further progression before intervention, aspects of the forceps and caesarean procedures, and a lack of recent emergency obstetric training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Consultant obstetrician and gynaecologist; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out a further vaginal examination after an hour before deciding how to proceed with delivery
Wider context from the report “5. Dr ████████ gave evidence that his arranging to take Kobi’s mother to theatre and prepare for delivery, and then carrying out a further vaginal examination at that time, would stand in for a later examination to see how matters were progressing. This was not regarded as good practice by the expert on the basis, it would be better to carry out a further examination after an hour, and then decide how to proceed with the delivery .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Consultant obstetrician and gynaecologist; that does not assign responsibility.
PFD Monitor interpretation Lack of recent emergency obstetrics training
Wider context from the report “12. There was no evidence that Dr ████████ had undergone training in emergency obstetrics in the recent period prior 3 March 2019 . Dr ████████ has undergone training since 3 March 2019 but at the instigation of North Devon District Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Consultant obstetrician and gynaecologist; that does not assign responsibility.
PFD Monitor interpretation Rotation of the baby’s head alone during obstructed delivery
Wider context from the report “7. Dr ████████ proceeded with a forceps delivery of the baby’s head. The body did not follow and the cervix “retracted” (which Dr ████████ had not encountered before. Nor had Mr ████████ the expert witness). Dr ████████ cut the cervix and rotated the head and tried unsuccessfully to deliver the shoulders through the incision. Mr ████████ expert said in evidence the baby’s head on its own should never be rotated due to the damage this can cause .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Consultant obstetrician and gynaecologist; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately interpret CTG readings and the full clinical picture before proceeding to delivery
Wider context from the report “4. Further ████████ second statement 21.4.2020, refers to some consideration being given to variable decelerations and variabilities contained in the CTG trace when making his decision to proceed to delivery at that time. It was accepted by Dr ████████ Ms ████████ consultant and Mr ████████ expert, that the CTG readings were within normal range and would not be a reason to proceed to delivery at that time . Their evidence was it would be appropriate in light of the full clinical picture and the CTG readings to “wait and see” how matters progressed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Consultant obstetrician and gynaecologist; that does not assign responsibility.
PFD Monitor interpretation Failure to accept consultant assistance during the procedure
Wider context from the report “6. Dr ████████ did not accept the Consultant’s offer of assistance but regarded himself as fully competent to carry out the procedure.
” Open source report