8 Apr 2021 Raphael Maximilian Kolbe · Prevention of Future Deaths report West London
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Concerns raised 1
Failure to ensure fetal monitoring requirements during epidural siting are highlighted and followed View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
The Portland Hospital for Women and Children
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
The Portland Hospital for Women and Children
Implement clarified midwifery and anaesthetic responsibilities, including maintaining fetal monitoring and providing backup support during epidural insertion.
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The Portland Hospital for Women and Children
Conduct monthly audits to monitor whether the fetal-monitoring and staffing changes are embedded and identify potential issues.
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The Portland Hospital for Women and Children
Update the Fetal Monitoring and Epidural Analgesia in Labour policies to clarify staff responsibilities during epidural insertion.
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The Portland Hospital for Women and Children
Disseminate the clarified responsibilities through team meetings, multidisciplinary circulation and skills-and-drills training.
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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.
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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 ensure fetal monitoring requirements during epidural siting are highlighted and followed
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
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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 Implement clarified midwifery and anaesthetic responsibilities, including maintaining fetal monitoring and providing backup support during epidural insertion.
Verbatim wording from the response “As a result of the SI investigation, a number of changes were put in place. In relation to the matters referred to above, it was reiterated to all staff that the primary responsibility of the midwife was in relation to the baby’s fetal monitoring, and that if this could not be maintained whilst assisting the anaesthetist, then another midwife must support the anaesthetist so that the fetal monitoring is not compromised.” Source location 2021-0029-Response-from-The-Portland-Hospital-Redacted
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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 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
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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 Update the Fetal Monitoring and Epidural Analgesia in Labour policies to clarify staff responsibilities during epidural insertion.
Verbatim wording from the response “Whilst the learning from the SI was properly embedded within the Hospital, we acknowledge that in relation to the ‘budding’ system and the role of the anaesthetist, these changes were not properly reflected in the Portland’s written policy. We apologise for this, and can confirm that this has now been addressed within the following updated policies, attached for your consideration:” Source location 2021-0029-Response-from-The-Portland-Hospital-Redacted
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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 Disseminate the clarified responsibilities through team meetings, multidisciplinary circulation and skills-and-drills training.
Verbatim wording from the response “These clarifications have also been discussed in team meetings, circulated amongst the midwifery multi-disciplinary team (which includes the anaesthetists) and used in the training programme ‘skills and drills’.” Source location 2021-0029-Response-from-The-Portland-Hospital-Redacted
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15 Dec 2020 Eddie Coffey · Prevention of Future Deaths report Hertfordshire
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Concerns raised 1
Failure in basic medical care for foetal heart rate monitoring and management during labour View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care East and North Hertfordshire Teaching NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
East and North Hertfordshire Teaching NHS Trust
Enhance fetal monitoring training, including second-stage labour interpretation, maternal-pulse recognition, human factors and incident learning.
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East and North Hertfordshire Teaching NHS Trust
Employ a full-time fetal monitoring specialist midwife to provide guidance, teaching, CTG review and education leadership.
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East and North Hertfordshire Teaching NHS Trust
Roll out an intermittent auscultation and escalation competency package with case scenarios, small-group and annual training, competency assessment and pass-rate auditing.
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East and North Hertfordshire Teaching NHS Trust
Procure six standardised CTG machines that record maternal pulse and place the work under capital-committee and risk-register oversight.
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East and North Hertfordshire Teaching NHS Trust
Introduce a CTG-machine sticker requiring two independent maternal-pulse checks and signatures after transfer from MLU to CLU.
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East and North Hertfordshire Teaching NHS Trust
Develop and implement planned CTG interpretation and escalation actions to establish a robust process.
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Department of Health and Social Care
Award £9.4 million to support maternity safety pilots using investigation and research learning, training and expert guidance to improve childbirth practice.
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Department of Health and Social Care
Bring the coroner’s report to the attention of the Healthcare Safety Investigation Branch.
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Eddie Coffey · 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
Eddie Coffey was born at Lister Hospital in a poor state, with a low heart rate and symptoms of hypoxia, and required resuscitation before transfer to neonatal intensive care. He died at Luton & Dunstable Hospital from perinatal asphyxia. Inquest evidence identified gross failures in monitoring and managing the foetal heart rate during labour, and raised concerns about whether the same situation could recur and whether other maternity units were following incorrect guidelines.
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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 in basic medical care for foetal heart rate monitoring and management during labour
Wider context from the report “(2) Evidence was given at the inquest by a Consultant Obstetrician from Lister Hospital that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey might have survived.
(3) Evidence was given at the inquest by an independent Consultant Obstetrician that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey would more than likely have survived.
” Source location Eddie Coffey · Prevention of Future Deaths report
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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 Enhance fetal monitoring training, including second-stage labour interpretation, maternal-pulse recognition, human factors and incident learning.
Verbatim wording from the response “In order to mitigate against this risk, the Trust is committed to enhancing our already well established Fetal Monitoring training and in particular enhancing the training provided to staff with regards to the second stage of labour. The importance of this issue is highlighted in every Fetal Monitoring lecture as maternal pulse features and characteristics are included as well as being included in an element of the Human Factors training that is given. The intended impact of this is to ignite professional curiosity and to encourage clinicians to actively seek out to exclude maternal pulse. Furthermore, since 20 January 2020 the trust has employed a full time fetal monitoring specialist midwife for 12 months.” Source location 2020-0287-Response-from-Lister-Hospital-Redacted
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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 Employ a full-time fetal monitoring specialist midwife to provide guidance, teaching, CTG review and education leadership.
Verbatim wording from the response “In order to mitigate against this risk, the Trust is committed to enhancing our already well established Fetal Monitoring training and in particular enhancing the training provided to staff with regards to the second stage of labour. The importance of this issue is highlighted in every Fetal Monitoring lecture as maternal pulse features and characteristics are included as well as being included in an element of the Human Factors training that is given. The intended impact of this is to ignite professional curiosity and to encourage clinicians to actively seek out to exclude maternal pulse. Furthermore, since 20 January 2020 the trust has employed a full time fetal monitoring specialist midwife for 12 months.” Source location 2020-0287-Response-from-Lister-Hospital-Redacted
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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 Roll out an intermittent auscultation and escalation competency package with case scenarios, small-group and annual training, competency assessment and pass-rate auditing.
Verbatim wording from the response “In response to your fourth point, actions have been developed to further strengthen the training in relation to second stage fetal monitoring interpretation. A second stage training update was delivered on 19 January 2021 which focussed on fetal monitoring and recognising the signs to differentiate between maternal pulse and fetal heart rate, highlighting learning from themes and incidents. Further sessions have been planned in this regard. An Intermittent Auscultation and escalation competency package, using added case scenarios including small group sessions and annual training, is being rolled out to the Midwifery-Led-Unit (MLU) midwives supported by a plan to role this out to all midwives. This will include a competency - based assessment and a requirement to record pass rates for ongoing auditing and assurance.” Source location 2020-0287-Response-from-Lister-Hospital-Redacted
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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 Procure six standardised CTG machines that record maternal pulse and place the work under capital-committee and risk-register oversight.
Verbatim wording from the response “Notwithstanding the training that has been implemented already at the Trust, it is accepted that CTG technology is not straightforward. This has led to a review being undertaken of the CTG machines currently in use within the Trust. As a department, Maternity are working towards standardising equipment in line with best practice. Review of the CTG machines currently in use has identified that 6 new machines are required which would then mean that all of the machines in use are the same and all would record maternal pulse on the CTG trace. Further work towards the procurement of these machines is ongoing and being reviewed by our Capital Equipment Committee. This issue will be added to the risk register which will ensure oversight and enable clear monitoring on a regular basis.” Source location 2020-0287-Response-from-Lister-Hospital-Redacted
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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 Introduce a CTG-machine sticker requiring two independent maternal-pulse checks and signatures after transfer from MLU to CLU.
Verbatim wording from the response “Moreover, in terms of immediate practical steps taken, we are in the process of producing a visual sticker that will go at the front of a CTG machine after a woman is transferred from MLU to CLU. This sticker will include a box for two individuals to check and sign that they have independently palpated maternal pulse. This process will be in place by the end of February 2021.” Source location 2020-0287-Response-from-Lister-Hospital-Redacted
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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 Develop and implement planned CTG interpretation and escalation actions to establish a robust process.
Verbatim wording from the response “to CTG monitoring with a number of elements in relation to the management of CTG interpretation and escalation. We have planned for a number of actions going forward in order to ensure that we have a robust process in place in respect of these. Please see the attached excel spreadsheet for full sight of the CTG action plan, some of which are detailed above and the work is ongoing.” Source location 2020-0287-Response-from-Lister-Hospital-Redacted
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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 Award £9.4 million to support maternity safety pilots using investigation and research learning, training and expert guidance to improve childbirth practice.
Verbatim wording from the response “In addition, £9.4million was awarded in the 2020 Spending Review to support maternity safety pilots that will include fresh learning from recent investigations and academic research to be used to improve clinical practice during childbirth, and cutting-edge training and expert guidance to improve practice and avoid harm to babies.” Source location 2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
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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 Bring the coroner’s report to the attention of the Healthcare Safety Investigation Branch.
Verbatim wording from the response “Finally, my officials have brought your report to the attention of the Healthcare Safety Investigation Branch (HSIB). HSIB is a key part of our commitment to improve patient safety and the culture of learning in the NHS. The HSIB conduct independent maternity investigations that meet the Each Baby Counts criteria and a defined criteria for maternal deaths so that the NHS learns quickly from what went wrong and uses this to prevent future tragedies. Where HSIB identifies systemic risks, it can consider making national recommendations for system change.” Source location 2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Trusts are responsible for implementing the Saving Babies’ Lives Care Bundle and appointing fetal-monitoring leads.
Verbatim wording from the response “In relation to monitoring fetal wellbeing, NHS Trusts are being asked to implement the saving babies lives bundle. Element 4 of the Saving Babies Lives Care Bundle Version 2 (SBLCBv2)⁶ already states there needs to be one lead with the responsibility of improving the standard of fetal monitoring. NHS Trusts are now being asked to ensure that a second lead is identified so that every unit has a lead midwife and a lead obstetrician in place to lead best practice, learning and support. This will include regular training sessions, review of cases and ensuring compliance with the SBLCBv2 and national guidelines.” Source location 2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
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18 Feb 2020 Zachary James Johnson · Prevention of Future Deaths report Black Country
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Concerns raised 1
Lack of waterproof equipment for foetal heart rate auscultation during birthing pool births View source
This report raised 5 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
Zachary James Johnson · 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
Zachary James Johnson was born in a birthing pool on 15 October 2016 after his foetal heart rate could not be auscultated for approximately 38 minutes because no working waterproof sonicaid was available. He was born floppy and unresponsive, and problems occurred during resuscitation, including incorrect ventilation-to-compression ratios, a period without chest compressions, and an interruption in airway management during transfer to hospital. The concerns included the availability of appropriate monitoring equipment and insufficiently frequent mandatory refresher training in newborn life support skills.
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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 Lack of waterproof equipment for foetal heart rate auscultation during birthing pool births
Wider context from the report “(1) During the course of the inquest, I heard evidence that Zachary’s mother was permitted to enter a birthing pool to give birth in the known absence of a waterproof sonicaid . The lack of such equipment prevented the auscultation of the foetal heart rate . This was a matter I found causative of Zachary’s death.
” Source location Zachary James Johnson · Prevention of Future Deaths report
Open source report
24 Jul 2019 Xander Curran-Pass · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Failure to closely observe a concerning cardiotocograph View source Failure to review cardiotocography after induction of labour commenced View source
This report raised 8 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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Xander Curran-Pass · 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
Xander Curran-Pass was delivered by category C Caesarean Section on 15 September 2018 after reduced fetal movement, delayed induction of labour, and concerning CTG findings. Resuscitation was unsuccessful and he died; post-mortem examination identified poor placental function associated with chronic villitis and thrombotic vasculopathy. The substantive concerns included delays in review and delivery, inadequate monitoring and documentation, and unclear or inconsistent processes for managing induction of labour and reduced fetal movement.
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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 closely observe a concerning cardiotocograph
Wider context from the report “9. The CTG at 07.09 was concerning from the early stages but the evidence suggested that it was not closely observed ;
” Source location Xander Curran-Pass · 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 Failure to review cardiotocography after induction of labour commenced
Wider context from the report “10. The second CTG after IOL commenced was not reviewed .
” Source location Xander Curran-Pass · Prevention of Future Deaths report
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28 May 2019 Maia Hazel Ann Strachan · Prevention of Future Deaths report Newcastle upon Tyne
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Concerns raised 1
Failure to use Foetal Scalp Electrodes for critical fetal distress information View source
This report raised 5 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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Maia Hazel Ann Strachan · 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
Maia Hazel Ann Strachan was born on 6 July 2017 and died in hospital on 7 July 2017 after a complicated delivery involving shoulder dystocia, hypoxic ischaemic encephalopathy and severe macrosomia. The report identified concerns about inaccurate and suboptimal ultrasound assessment, inaccessible obstetric and diabetic records, missed opportunities for Caesarean delivery and joint decision-making, fetal scalp electrode use, documentation, and dissemination of expert findings.
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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 use Foetal Scalp Electrodes for critical fetal distress information
Wider context from the report “(4) Foetal Scalp Electrode:
The use of Foetal Scalp Electrodes (FSE) provide critical information in respect of foetal distress and the time implications thereof .
The Trust should draft and implement a clear and comprehensive Local Policy/Protocol for FSE use.
” Source location Maia Hazel Ann Strachan · Prevention of Future Deaths report
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18 Jul 2018 Mohamed Rahman · Prevention of Future Deaths report Manchester (West)
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Concerns raised 2
Failure to formally record the exact time of cessation of fetal heart activity View source Failure to perform the interval fetal heart check at least 20 minutes later and for a full 2 minutes View source
This report raised 4 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
Mohamed Rahman · 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 Mohamed Rahman was born at 01:45 on 17 February 2018 after an elective feticide procedure and was confirmed dead at 02:48 that day. The principal concerns were that fetal asystole was not unequivocally confirmed before discharge, that the mother and professionals were unprepared for the birth, and that documentation and guidance about confirming fetal demise and explaining the procedure to parents required consideration.
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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 formally record the exact time of cessation of fetal heart activity
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound.
” Source location Mohamed Rahman · 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 Failure to perform the interval fetal heart check at least 20 minutes later and for a full 2 minutes
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound.
” Source location Mohamed Rahman · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of a documented regime for regular fetal-heart auscultation after maternal opiate administration View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Elouise Winship · 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
Elouise Winship was delivered unresponsive on 11 March 2011, was resuscitated, and died 13 hours later. Concerns included the absence of a documented standard regime for fetal heart auscultation after maternal opiates and the need for further maternal examination and fresh observations following a recognisable change in condition during labour.
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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 Lack of a documented regime for regular fetal-heart auscultation after maternal opiate administration
Wider context from the report “1. That although a Local Serious Review was undertaken following Elouise’s death in which it was agreed that the fetal heart should have been auscultated on a regular basis following administration of opiates to the mother, there is no documented regime by which this has been adopted into standard practice .
” Source location Elouise Winship · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.