First reported 1 Mar 2018•Latest report 16 Sep 2025
Definition
What this concern includes
Includes failures in the dedicated emergency management of breech birth, including recognition of breech presentation or delayed delivery, application and adequacy of JRCALC or equivalent guidance, decision-making about intervention or transfer to obstetric care, paramedic competence and access to continuing expert support.
Not included
Excludes general maternity staffing, training or obstetric escalation deficiencies where breech birth is not the material safety condition.
Excludes routine antenatal birth planning, mode-of-delivery counselling and non-emergency maternity care unless the assertion specifically concerns emergency management of breech birth.
Excludes failures in neonatal care after delivery where the breech-birth emergency-management process operated adequately.
Excludes generic ambulance response, referral or clinical-guidance deficiencies without a supported breech-birth context.
Reports
3
Distinct published reports
Individual concerns
5
A report can raise multiple concerns
Date range
2018–2025
First to latest report issue date
Stated actions
11
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Association of Ambulance Chief Executives2
Department of Health and Social Care1
East Midlands Ambulance Service NHS Trust1
Healthcare Safety Investigation Branch1
Health Services Safety Investigations Body1
Joint Royal Colleges Ambulance Liaison Committee1
NHS Birmingham and Solihull Integrated Care Board1
NHS Black Country Integrated Care Board1
NHS Coventry and Warwickshire Integrated Care Board1
NHS Herefordshire and Worcestershire Integrated Care Board1
NHS Shropshire, Telford and Wrekin Integrated Care Board1
NHS Staffordshire and Stoke-on-Trent Integrated Care Board1
Stepping Hill Hospital1
West Midlands Ambulance Service University NHS Foundation Trust1
Health-sector membership body2
NHS trust2
Executive non-departmental public body1
Healthcare site1
Health professional committee1
Integrated care board1
Ministerial department1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Birmingham and Solihull
Concerns raised2
Lack of mandatory and comprehensive paramedic training in obstetric emergencies
Failure to adhere to clinical guidance for assessing and managing delayed breech birth
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Provide regulated obstetric-emergency and breech-birth training through the AAP and Graduate Paramedic Induction programmes.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Deliver practical breech-birth simulation sessions using Victoria mannequins and other maternity training equipment, updated following the new guidance.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Purchase and deploy five Victoria birthing mannequins for realistic obstetric-emergency simulation training.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Include obstetric emergencies, including breech birth, in mandatory face-to-face refresher training for all ambulance clinicians during 2026–2027.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 September 2025.
Action
Provide continuing professional development through maternity roadshows, themed maternity learning and expert-led obstetric-emergency simulation.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Relaunch the e-PROMPT obstetric-emergency course and make it available for clinicians to complete.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Update the paramedic breech birth algorithm with manoeuvre guidance, illustrations, videos and step-by-step advice.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Require ambulance clinicians to review the updated JRCALC breech-delivery guidance during Clinical Supervision shifts.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Update and enhance the JRCALC breech-birth guideline using evidence review, expert consensus, paramedic usability testing, images and instructional videos.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
The e-PROMPT course was unavailable because guidance updates paused it, not because resourcing prevented clinicians from completing it.
Stated by West Midlands Ambulance Service University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Relevant obstetric content in broader refresher training and CPD, alongside accessible JRCALC guidance, is considered sufficient without a standalone mandatory module.
Stated by West Midlands Ambulance Service University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Responsibility for paramedic training and education falls outside AACE’s remit.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
Training concerns were shared with ambulance education and clinical networks for consideration by their organisations.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Qualified paramedic maternity training is the responsibility of individual ambulance trusts.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
AACE has no control over allocating specific funding for maternity training.
Stated by Association of Ambulance Chief ExecutivesUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West Sussex
Concerns raised1
Insufficient JRCALC guidance on emergency management of footling breech presentation
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised2
Lack of paramedic experience in managing footling breech deliveries
Failure to provide or seek continuing expert support during footling breech deliveries
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Develop standardised minimum criteria for requesting remote or on-scene obstetric support.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 June 2018.
Action
Implement standardised minimum criteria for requesting remote or on-scene obstetric support.
Stated by East Midlands Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 June 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The HSIB cannot investigate this case because it occurred before the organisation became operational and falls outside its investigation criteria.
Stated by Health Services Safety Investigations BodyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Operational concerns are for the involved NHS trusts to address.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
HSIB cannot investigate incidents occurring before its establishment because they do not meet its investigation criteria.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures in the dedicated emergency management of breech birth, including recognition of breech presentation or delayed delivery, application and adequacy of JRCALC or equivalent guidance, decision-making about intervention or transfer to obstetric care, paramedic competence and access to continuing expert support.
