Concern over lack of training after death of baby

The Royal Berkshire NHS Trust said it was "truly sorry" will implement changes

A coroner has highlighted her concerns about the limited level of training given to doctors following the death of a baby who was injured during a caesarean section.

An inquest heard how during Louisa Walker's birth, at Reading's Royal Berkshire Hospital, a doctor tried to move her head resulting in skull fractures and intracranial haemorrhage. She died just over a month later.

After the birth in May 2024, the Royal Berkshire NHS Trust said it was "committed to learning and changing our practice to avoid recurrence".

But Berkshire coroner Heidi Connor has questioned that commitment given only 17% of the trust's obstetricians had undertaken new training to prevent a similar incident.

The coroner outlined her concerns in a Regulation 28 Report, which is used to try highlight actions that should be taken by authorities or organisations to prevent similar deaths in the future.

Mrs Connor said: "If the trust is taking this matter very seriously and is committed to learning, I am concerned that 83% of their obstetricians have not undergone their training."

Mrs Connor has also written to the Royal College of Obstetricians and Gynaecologists calling for national guidance on how to deal with an impacted foetal head, which she said she understood had become "increasingly common".

The Royal Berkshire NHS Trust said: "We have worked closely with [Louisa's family] and captured their feedback to help inform our perinatal mortality review and that of the independent Maternity and New-born Safety Investigation.

"We are currently studying the coroner's findings and conclusions, and the matter of concern raised in the Regulation 28 Report, to ensure full and swift compliance with relevant clinical training requirements.

"The Trust Board's Quality Committee will further scrutinise the findings, and our response to the Regulation 28 Report, at their next meeting.

"If there are additional learnings that need attention we will, of course, implement them swiftly."

The trust is legally obliged to respond to the Regulation 28 report within 56 days.