Recurring concern

Failure to provide individualised pregnancy and birth risk assessment and planning

First to latest report 14 Oct 2013 — 5 Nov 2025

Reports that mention this concern
11
Times this concern has been raised
14
Stated actions linked to this concern
13

What this concern includes

Includes failures in pregnancy and birth risk assessment and planning where the report concerns individualised or holistic identification, communication, escalation, or management of risks to determine an appropriate birth plan, timing, or mode of delivery.

What is not included
  • Excludes generic failures in training, documentation, staffing, communication, or continuity that are not specifically tied to pregnancy and birth risk assessment and planning.
  • Excludes consent or risk-discussion deficiencies that do not concern the assessment and planning of pregnancy or birth risks.
  • Excludes failures concerning unrelated clinical risk assessments, medication dosing, monitoring, or other safety processes.

Reports and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner South London

    AI-generated summary

    Leo Deady · 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

    Leo Deady died at Queen Elizabeth Hospital at one hour of age following an undiagnosed breech presentation, which was first noticed when the mother was fully dilated. The report raised concerns about missed breech presentations, the risks of vaginal breech delivery, and the absence of national guidance on routine late-pregnancy scanning to detect breech presentation.

    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.

    PFD Monitor interpretation

    Failure to detect breech presentation before delivery

    Wider context from the report

    “(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed. The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high. Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed. The only certain way of detecting breech presentation is by scan. The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech. The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy. There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues. ”

    Source location

    Leo Deady · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Routine national late-pregnancy scanning is not considered beneficial based on existing evidence, so developing a national system is unnecessary.

    Verbatim wording from the response

    “In October 2008, the Cochrane Review into The Routine ultrasound in late pregnancy (after 24 weeks’ gestation) concluded that, based on existing evidence, routine late pregnancy ultrasound in low-risk or unselected populations does not confer benefit on mother or baby.”

    Source location

    2013-0369-Response-by-Department-of-Health
    Page 2 · response
    Published 19 December 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026