Elouise Winship · Prevention of Future Deaths report

On the 21st of March 2011 I commenced an investigation into the death of Elouise Winship (DOB 11.3.11, DOD 12.3.11). The investigation concluded at the end of the inquest on the 3rd of October 2014 and I recorded a conclusion of a death from natural causes, the cause of death being 1(a) Massive Aspiration of Amniotic Fluid and Meconium due to 1(b) Severe Intrauterine/intrapartal Asphyxia due to 1(c) Umbilical Cord Wrapped around the Baby.

The Circumstances of the death are that Elouise was resuscitated after being delivered unresponsive on the 11th of March 2011 but failed to survive beyond thirteen hours.

1. That although a Local Serious Review was undertaken following Elouise’s death in which it was agreed that the fetal heart should have been auscultated on a regular basis following administration of opiates to the mother, there is no documented regime by which this has been adopted into standard practice.

2. That it should be considered a good practice (which should if possible be incorporated into the care pathway) that there should be a further examination of mothers with fresh observations being undertaken following a recognisable change in the mother’s condition, regardless of the phase or anticipated progress of the labour.