8 Dec 2025 Syeda Meerab FATIMA · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2
Failure to eradicate persistent bullying and harassment in the maternity department View source Bullying culture within the maternity department View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Syeda Meerab FATIMA · 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
Baby Syeda was born prematurely by a difficult footling breech vaginal delivery after delays in preparing for and carrying out an emergency Caesarean section. She was born in a poor condition, required resuscitation, and died a few hours later. The principal concern was a wider, systemic bullying and hierarchical workplace culture in the maternity department at Good Hope Hospital, which was identified as contributing to delays in the emergency response.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to eradicate persistent bullying and harassment in the maternity department
Wider context from the report “8. What makes the Welfare Culture Report more shocking is that the Trust committed to addressing culture in 2023 following an independent review. The Trust’s Response to the 2023 culture review set out a plan and a roadmap to addressing cultural issues within the Trust. At the inquest into Syeda’s death, I heard evidence that the Trust has worked hard since 2023 to address culture, and that three monitoring criteria as stipulated by the CQC had been reduced from three to one. That is commendable. However, despite all of that work, it is clear that a culture of bullying and harassment has been allowed to persist and fester within the maternity department of Good Hope Hospital , undermining all of that hard work.
9. The PSII report was completed on 30/10/25 with the Workplace Culture report following thereafter. Under those reports, the Maternity department was tasked to explore NHS England’s Safe Learning Environment Charter (SLEC) to help to support a positive learning and working environment and for representatives from each MDT team to complete a self-assessment to identify areas of improvement. That Charter is available online (https://www.england.nhs.uk/mat-transformation/safe-learning-environment-charter/). In evidence, I was advised that the Safe Learning Charter has been widely adopted throughout the Trust, which is concerning in itself as it is clear that it was not fully adopted within the maternity department at Good Hope Hospital before this tragic incident. Having considered the Charter however, and the evidence of witnesses at the inquest, I am not confident that this will be the “silver bullet” to the problem, particularly as two years’ work by the Trust has failed to address and eradicate the problem already.
10. It is recognised that tackling issues of workplace cultural is not a “sprint to the finish line” as there will never be a proverbial “finish line” - it is an ongoing process and which requires the input and buy-in of all employees to ensure that the workplace is a safe place for all. However, it is clear that more must be done to address this issue so that both staff and patients’ lives are not at risk.
” Source location Syeda Meerab FATIMA · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Bullying culture within the maternity department
Wider context from the report “5. The culture is described in the Workplace Culture Report as being “hierarchical” both between the obstetrics and midwifery teams, as well as being within those teams as well. The report indicates that lower banding staff and non-maternity staff cannot offer opinions or views; band 7 midwives make any staff below that banding feel unwelcome to set foot in the office; the band 7 midwives are reported to be “cliquey” and some have suggested that the culture stems from those band 7s and is top-down.
6. The department is described as “cold and unwelcoming” to new starters and outside staff members and has a “bullying culture” which is not felt or seen at other hospitals within the Trust.
7. The Delivery Suite/Labour ward is described as being the midwives’ “territory” with staff encountering considerable anxiety when urgent decision making is concerned. This is particularly shocking – patients’ lives should not be put at risk because of workplace culture.
” Source location Syeda Meerab FATIMA · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a comprehensive review of the issues identified in the Regulation 28 notice.
Verbatim wording from the response “Whilst a significant amount of work has been undertaken, we are aware that further work is required. We have undertaken a comprehensive review of the issues identified within the Regulation 28 notice and have aligned our response with the ongoing Maternity and Neonatal Improvement Programme (MNIP) under the NHS England Maternity Safety Support Programme (MSSP). This programme focuses on leadership, culture, inclusion, communication, and governance to ensure sustainable improvement.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver enhanced multiprofessional leadership development, civility, active bystander and cultural humility training.
Verbatim wording from the response “Key initiatives we will be undertaking include:” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct Safety Champion walkarounds and Cappuccini checks to reinforce senior visibility, escalation routes and respectful communication.
Verbatim wording from the response “Key initiatives we will be undertaking include:” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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22 Feb 2024 Mia Janin · Prevention of Future Deaths report North London
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Concerns raised 2
Ongoing gender-based bullying at JFS View source Failure of gender-based bullying initiatives to gain the confidence of female students View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
JFS
Appoint a full-time safeguarding lead and five full-time safeguarding officers.
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JFS
Deliver formal PSHE teaching addressing personal development, relationships, equality, conduct, abuse, coercion, boundaries, and discrimination.
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JFS
Implement CPOMS as a centralised reporting, allocation, follow-up, and trend-monitoring system for safeguarding concerns.
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JFS
Implement an anonymous reporting system on the school website.
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JFS
Conduct coordinated safeguarding monitoring through student check-ins, fortnightly multi-disciplinary reviews, CPOMS follow-up, and monthly governor review of significant concerns.
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JFS
Review and publish anti-bullying and behaviour policies with provisions addressing sexist and gender-based bullying and consistent sanctions.
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JFS
Deliver staff and student education on sexual harassment, reporting, social technology, consent, assertiveness, abuse, safeguarding, and positive peer communication.
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JFS
Run a staffed lunchtime Time to Talk forum for students to discuss concerns.
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JFS
Create a student voice group and a Student Digital Leaders group to promote equality and positive peer communication.
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JFS
Work with Jewish Women’s Aid to develop drop-down days aimed at embedding cultural change.
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AI-generated summary
Mia Janin · 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
Mia Janin was found deceased at home on 12 March 2021, aged 14, after taking her own life. The report describes bullying behaviour by some male students, including gender-based bullying, and hostile responses to a social media post. Concerns were raised about ongoing gender-based bullying at JFS and whether the school’s initiatives had gained the confidence of some female students.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Ongoing gender-based bullying at JFS
Wider context from the report “(1) Any ongoing gender based bullying at JFS gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future; and
(2) The initiatives introduced by JFS to address gender based bullying following Mias death do not appear to have gained the confidence of some JFS female students, which gives rise to a concern that the circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
” Source location Mia Janin · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of gender-based bullying initiatives to gain the confidence of female students
Wider context from the report “(1) Any ongoing gender based bullying at JFS gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future; and
(2) The initiatives introduced by JFS to address gender based bullying following Mias death do not appear to have gained the confidence of some JFS female students , which gives rise to a concern that the circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
” Source location Mia Janin · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint a full-time safeguarding lead and five full-time safeguarding officers.
Verbatim wording from the response “a. The appointment of a full-time safeguarding lead.” Source location Response from The Jewish Free School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver formal PSHE teaching addressing personal development, relationships, equality, conduct, abuse, coercion, boundaries, and discrimination.
Verbatim wording from the response “g. The delivery of formal Personal, Social and Health Education (PSHE) teaching in the curriculum to address all aspects of personal development, during which expectations of appropriate behaviour regarding all aspects of student conduct are made clear.” Source location Response from The Jewish Free School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement CPOMS as a centralised reporting, allocation, follow-up, and trend-monitoring system for safeguarding concerns.
Verbatim wording from the response “h. The introduction of ‘Child Protection Online Management System’ (CPOMS) as a centralised reporting tool used by all staff across the school.” Source location Response from The Jewish Free School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an anonymous reporting system on the school website.
Verbatim wording from the response “j. The introduction of an anonymous reporting system on the school website.” Source location Response from The Jewish Free School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct coordinated safeguarding monitoring through student check-ins, fortnightly multi-disciplinary reviews, CPOMS follow-up, and monthly governor review of significant concerns.
Verbatim wording from the response “All students at JFS are known and supported. JFS now has multiple coordinated systems that work to protect children, and staff work to ensure safeguarding is effective. To ensure there are no communication gaps between the Safeguarding and Behaviour teams, fortnightly review meetings are attended by the Designated Safeguarding Lead, Mental Health and Wellbeing Lead, Special Educational Needs Coordinator, Safeguarding Officer and Director of Key Stage. All students in JFS have a safeguarding rating between 1 and 4, representing the highest level of risk and 1 representing no known risk. Students receive personal check-ins from the Safeguarding Officers to understand each individual’s circumstances.” Source location Response from The Jewish Free School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and publish anti-bullying and behaviour policies with provisions addressing sexist and gender-based bullying and consistent sanctions.
Verbatim wording from the response “In respect of your concerns in relation to ongoing issues in respect of, or initiatives in relation to gender-based bullying, JFS has an anti-bullying policy that is reviewed annually. The current version of the anti-bullying policy was published in January 2024, a copy of which has already been provided to the Court, which clearly states that “Bullying of any sort will not be” Source location Response from The Jewish Free School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver staff and student education on sexual harassment, reporting, social technology, consent, assertiveness, abuse, safeguarding, and positive peer communication.
Verbatim wording from the response “JFS is pro-active in educating students about the gender-based bullying and equality. The school has implemented a mix of student-led, teacher-led and externally-led sessions including:” Source location Response from The Jewish Free School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a staffed lunchtime Time to Talk forum for students to discuss concerns.
Verbatim wording from the response “l. The introduction of ‘Time to Talk’ which runs every lunchtime and is staffed by two experienced members of staff. This is a forum for students to relax and talk about anything that is on their mind.” Source location Response from The Jewish Free School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a student voice group and a Student Digital Leaders group to promote equality and positive peer communication.
Verbatim wording from the response “• Creation of a 160-strong student voice group, 40 students of which champion equality in the school.” Source location Response from The Jewish Free School
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Jewish Women’s Aid to develop drop-down days aimed at embedding cultural change.
Verbatim wording from the response “JFS is constantly seeking ways to improve its provision and, going forward, will be working with the Jewish Women’s Aid group to build a series of drop-down days to further embed cultural change.” Source location Response from The Jewish Free School
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evidence of gender-based bullying largely predates the changes implemented following Mia’s death.
Verbatim wording from the response “Although JFS considers that much of the evidence referred to in the Regulations 28 Report that was provided by some JFS students after Mia’s death to the police and Ofsted pre-dates the changes implemented following Mia’s death, JFS nevertheless takes your concerns very seriously and has carefully reviewed and considered the matters within the Regulation 28 Report.” Source location Response from The Jewish Free School
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20 Nov 2017 Robert John Richards · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Inadequate systems for managing bullying View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Robert John Richards · 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
Robert John Richards died by suicide after being found hanging by a sheet in his cell at HMP Wandsworth on 29 July 2014. The report identified concerns about bullying, extortion, inadequate risk management and communication, unsuitable cell allocation, staffing and training, and failings in resuscitation equipment and procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate systems for managing bullying
Wider context from the report “1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place , too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies.
” Source location Robert John Richards · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.