Recurring concern

Failure to provide timely and reliable fresh-eyes reviews in maternity care

First to latest report 8 Apr 2021 — 3 Apr 2022

Reports that mention this concern
3
Times this concern has been raised
4
Stated actions linked to this concern
6

What this concern includes

Includes failures of the maternity fresh-eyes review process, including inadequate timing or frequency, unclear or inconsistent guidance, and failure to complete reviews by the required reviewing clinician.

What is not included
  • Excludes generic training, staffing, documentation or governance deficiencies unless they are specifically tied to the fresh-eyes review process.
  • Excludes unrelated clinical reviews, assessments or monitoring processes.
  • Excludes failures concerning maternity care that do not involve the fresh-eyes review requirement.

Reports and published responses 3 reports

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

  1. West Yorkshire (Western)

    AI-generated summary

    Edward Arthur AKROYD · 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

    Edward Arthur Akroyd was delivered by forceps on 13 January 2018 at Calderdale Royal Hospital after concerns arose during his mother’s labour, including pre-eclampsia and abnormal CTG tracing. He was transferred to Leeds General Infirmary for intensive treatment and died there on 17 January 2018. The principal concerns included inadequate monitoring and treatment of his mother’s elevated blood pressure, incomplete handover and medical records, failure to communicate laboratory results, and delayed recognition and interpretation of non-reassuring CTG findings.

    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 undertake second-midwife fresh eyes review

    Wider context from the report

    “10. From the evidence presented, and in accordance with trust guidelines, a second midwife should have undertaken a fresh pair of eyes review at 18.40 hours, this did not occur. I understand that such guidelines are put in place so as to ensure that key features are not missed and appropriate treatment plans are put in place. I am concerned that if such reviews do not occur it presents a risk to the wellbeing of expectant mothers and their unborn child ”

    Source location

    Edward Arthur AKROYD · Prevention of Future Deaths report
    Page 3 · concerns

    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 to undertake timely fresh eyes review

    Wider context from the report

    “1. Whilst Mrs Akroyd was being cared for at Huddersfield Birthing Centre, her blood pressure was not checked and fresh eyes review was not undertaken at the appropriate time in accordance with the trust guidance. I am concerned that if this were to reoccur there is a real risk of missed opportunities to identify significant changes which could impact upon both the mother and unborn baby’s wellbeing. ”

    Source location

    Edward Arthur AKROYD · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Develop and implement a standard operating procedure requiring hourly fresh-eyes clinical reviews in labour at the Birth Centre.

    Verbatim wording from the response

    “The second issue is the fresh eyes review. The Trust’s Maternity Services regularly review and update local guidelines.”

    Source location

    Response from Calderdale and Huddersfield NHS Foundation Trust (1)
    Page 2 · response
    Published 8 March 2022

    Open published response

    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

    Existing guidance, training, governance review and feedback arrangements are considered sufficient to address compliance with maternal monitoring and fresh-eyes reviews.

    Verbatim wording from the response

    “The second issue is the fresh eyes review. The Trust’s Maternity Services regularly review and update local guidelines.”

    Source location

    Response from Calderdale and Huddersfield NHS Foundation Trust (1)
    Page 2 · response
    Published 8 March 2022

    Open published response

    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

    The midwife’s reviewed practice and the registrar’s timely assessment are considered sufficient to address the fresh-eyes review concern.

    Verbatim wording from the response

    “A fresh eyes assessment should be undertaken by a second person qualified to assess the CTG. This does not have to be a midwife, an Obstetrician at registrar level would be regarded as suitably qualified to undertake a fresh eyes assessment. In this case the Registrar reviewed Mrs Akroyd at 18.53. This was however 13 minutes later than the best practice of 60 minutes.”

    Source location

    Response from Calderdale and Huddersfield NHS Foundation Trust (1)
    Page 6 · response
    Published 8 March 2022

    Open published response

  2. Inner North London

    AI-generated summary

    Ziggy Dylan MITCHELL-STAGG · 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

    Ziggy was born by emergency Caesarean section at Homerton University Hospital on 3 April 2021 in a very compromised state and died a few hours later. The concerns included inconsistent terminology for meconium, a lack of a medical-record entry by the attending obstetric registrar after 3.46am, no local policy on centralised CTG monitoring, and a trust policy providing for fresh-eyes reviews every two hours rather than the hourly national guidance.

    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

    Inadequate frequency of fresh eyes reviews for women in labour

    Wider context from the report

    “4. There is national guidance that there should be a fresh eyes review every hour for women in labour, but your trust policy indicates only every two hours. It seems that the trust policy merits reconsideration, either to amend it or to record why there is a departure from national guidance. ”

    Source location

    Ziggy Dylan MITCHELL-STAGG · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Liaise with neighbouring trusts to understand how they deliver hourly holistic fresh-eyes reviews.

    Verbatim wording from the response

    “We agree that our Trust guidance needs revisiting and our first step in that process is to liaise with other neighbouring Trusts of similar acuity to learn from them and understand how they adhere to an hourly fresh eyes which not only assesses fetal well-being but provides a holistic view. We will then create our own action plan for implementation.”

    Source location

    2021-0425-Homerton-University-Hospital_Published
    Page 2 · response
    Published 22 December 2021

    Open published response

    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 Trust action plan for implementing an hourly holistic fresh-eyes review after learning from neighbouring trusts.

    Verbatim wording from the response

    “We agree that our Trust guidance needs revisiting and our first step in that process is to liaise with other neighbouring Trusts of similar acuity to learn from them and understand how they adhere to an hourly fresh eyes which not only assesses fetal well-being but provides a holistic view. We will then create our own action plan for implementation.”

    Source location

    2021-0425-Homerton-University-Hospital_Published
    Page 2 · response
    Published 22 December 2021

    Open published response

    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

    A true hourly fresh-eyes review was not achievable during the previous trial, limiting immediate implementation of the national guidance.

    Verbatim wording from the response

    “The trust realises that the hourly ‘fresh eyes’ review is embedded within national guidance and we want to strive to achieve this. The trust previously trialled this in 2019 however it was found that a true fresh eyes review was not achievable every hour.”

    Source location

    2021-0425-Homerton-University-Hospital_Published
    Page 2 · response
    Published 22 December 2021

    Open published response

  3. West London

    AI-generated summary

    Raphael Maximilian Kolbe · 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

    Raphael Maximilian Kolbe was delivered at term after an uneventful pregnancy, but a cord prolapse during delivery was not recognised until fetal compromise had occurred. He died six weeks later in Kingston Hospital after transfer for palliative care. The concerns identified included inadequate monitoring during induction labour and epidural re-siting, unclear staff roles, and differences between hospital policy and practice.

    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

    Lack of clear hospital guidance for regular review by another midwife or obstetrician

    Wider context from the report

    “It became apparent during the inquest that although a great deal of positive work, reflection and retraining has taken place and amendments to the Hospital policies and guidelines, the policy does still not reflect practise. This is particularly so in respect of the roles of the primary midwife, the second midwife in support and the anaesthetist when an epidural is being sited. In order for greater clarification and protection of the fetal well being, further consideration should be given to ensure all attending personnel are aware of their role. The requirements for fetal monitoring during this particular procedure should be highlighted and practise should reflect hospital policy. The requirement for “fresh eyes” remains under ongoing consideration to encourage and support regular review from another midwife or obstetrician and the hospital are continuing to work on an Action plan to implement best practise. While this is always an area that remains under review, clear guidance from the hospital would best support the staff and facilitate better outcomes. ”

    Source location

    Raphael Maximilian Kolbe · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 monthly audits to monitor whether the fetal-monitoring and staffing changes are embedded and identify potential issues.

    Verbatim wording from the response

    “The investigating team created an action plan to address the areas for learning, including the above, and put in place monthly audits to ensure the changes were embedded. These monthly audits can also be used for early identification of any potential issues, and therefore will continue to be an ongoing part of the Hospital’s audit process.”

    Source location

    2021-0029-Response-from-The-Portland-Hospital-Redacted
    Page 1 · response
    Published 9 February 2021

    Open published response

    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

    Operate the hourly second-midwife or designated senior-staff ‘fresh eyes’ fetal-monitoring check procedure and review its use through monthly audits.

    Verbatim wording from the response

    “At the Portland, all maternity patients admitted to the labour ward are allocated a midwife and are cared for on a 1-2-1 basis. The fresh eyes policy at the Portland Hospital is an additional step for a second midwife to carry out the ‘fresh eyes’ check on an hourly basis, the practice is that each midwife will ‘buddy up’ usually with the midwife in the next labour room to undertake the checks. This is agreed with the Labour Co-Ordinator at the beginning of the shift. When the acuity on the ward does not support the above, another midwife, the maternity labour ward co-ordinator / Labour Ward Sister, is contacted to carry out the check.”

    Source location

    2021-0029-Response-from-The-Portland-Hospital-Redacted
    Page 2 · response
    Published 9 February 2021

    Open published response

    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

    Use the K2 electronic-records system’s hourly pop-up reminder to prompt fresh-eyes review of fetal heart traces during CTG monitoring.

    Verbatim wording from the response

    “The Portland Hospital for Women and Children introduced the K2 electronic records system within maternity a number of years ago, this system is provided by K2 Medical Systems and is used widely throughout the NHS and Independent sector. A function within the K2 system is an hourly pop-up reminder for the midwife to request a ‘fresh eyes’ review of the fetal heart trace when CTG monitoring is taking place. This reminder is not a ‘hard stop’ within the system as it would prevent further action and monitoring of the patient that may be clinically indicated.”

    Source location

    2021-0029-Response-from-The-Portland-Hospital-Redacted
    Page 2 · response
    Published 9 February 2021

    Open published response

    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

    Existing hourly fresh-eyes checks, midwife buddying, coordinator checks, clear policy and monthly audits provide the hospital’s ongoing response.

    Verbatim wording from the response

    “At the Portland, all maternity patients admitted to the labour ward are allocated a midwife and are cared for on a 1-2-1 basis. The fresh eyes policy at the Portland Hospital is an additional step for a second midwife to carry out the ‘fresh eyes’ check on an hourly basis, the practice is that each midwife will ‘buddy up’ usually with the midwife in the next labour room to undertake the checks. This is agreed with the Labour Co-Ordinator at the beginning of the shift. When the acuity on the ward does not support the above, another midwife, the maternity labour ward co-ordinator / Labour Ward Sister, is contacted to carry out the check.”

    Source location

    2021-0029-Response-from-The-Portland-Hospital-Redacted
    Page 2 · response
    Published 9 February 2021

    Open published response

    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

    The hourly fresh-eyes reminder is not a hard stop because this could prevent clinically indicated further monitoring or action.

    Verbatim wording from the response

    “The Portland Hospital for Women and Children introduced the K2 electronic records system within maternity a number of years ago, this system is provided by K2 Medical Systems and is used widely throughout the NHS and Independent sector. A function within the K2 system is an hourly pop-up reminder for the midwife to request a ‘fresh eyes’ review of the fetal heart trace when CTG monitoring is taking place. This reminder is not a ‘hard stop’ within the system as it would prevent further action and monitoring of the patient that may be clinically indicated.”

    Source location

    2021-0029-Response-from-The-Portland-Hospital-Redacted
    Page 2 · response
    Published 9 February 2021

    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