Evidence
Date of report: 19/09/2024
Ref: 2024-0504
Deceased name: Evelyn March
Coroners name: Kevin McLoughlin
Coroners Area: West Yorkshire (East)
Category: Child Death (from 2015)
This report is being sent to: Leeds Teaching Hospitals NHS Trust
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
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THIS REPORT IS BEING SENT TO:
1. Leeds Teaching Hospitals NHS Trust |
|
CORONER
I am Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (East) |
|
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
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INVESTIGATION and INQUEST
On 27.9.23 I commenced an investigation into the death of Evelyn Grace March aged 1 day. |
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CIRCUMSTANCES OF THE DEATH
Baby Evelyn Grace March was born on Tuesday 26.9.23 at 04:38 at Leeds General Infirmary, following a prolonged labour. She and her parents were discharged home 4 hours after the birth (08:49 hours). |
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CORONER’S CONCERNS
During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. The Mother endured a prolonged labour and had little sleep from Sunday (24.9.23) until her baby was born at 04:38 hours on Tuesday (26.9.23). She was exhausted. |
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ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. |
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YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely |
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COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (mother) and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. I have also sent it to Maternity and Newborn Safety Investigations and [REDACTED], Consultant Paediatric Pathologist who may find it useful or of interest. |
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Signed: KEVIN McLOUGHLIN Senior Coroner West Yorkshire (E) Date: 19 September 2024 |
The post Evelyn March: Prevention of Future Deaths Report appeared first on Courts and Tribunals Judiciary.
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