Recurring concern

Inadequate guidance for managing fetal infection

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First reported 3 Nov 2021•Latest report 24 Jun 2026

Definition

What this concern includes

Includes deficiencies in guidance, protocols or decision criteria specifically governing recognition, assessment, infection control, delivery decisions, microbiology advice and treatment of fetal infection or materially related fetal infection risks, including infection following feticide.

Not included

  • Excludes generic maternal infection guidance where fetal infection or a fetal infection risk is not the material concern.
  • Excludes general obstetric, neonatal or maternity guidance deficiencies that do not specifically concern fetal infection management.
  • Excludes failures in clinical care or treatment where the relevant fetal-infection guidance was available and the problem was only implementation.
  • Excludes guidance for confirmation of fetal demise, fetal monitoring or other fetal conditions unless the assertion also directly concerns management of fetal infection.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2021–2026

First to latest report issue date

Stated actions
2

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.

National Institute for Health and Care Excellence2
Aneurin Bevan University LHB1
Chief Executive of National Institution for Health and Care Excellence1
Chief Executive of Royal College of Midwives1
Chief Executive of Royal College of Obstetricians and Gynaecologists1
Department of Health and Social Care1
Healthcare Inspectorate Wales1
Royal College of Midwives1
Royal College of Obstetricians and Gynaecologists1
Worcestershire Acute Hospitals NHS Trust1

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.

  1. Gwent

    AI-generated summary

    Nola-Reign Morgan · 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

    Nola-Reign Morgan was born prematurely on 5 February 2024 after her mother developed suspected chorioamnionitis, and died three days later despite resuscitation and neonatal care. The report identified delays in transferring her mother to the labour ward and high dependency unit, a period without fetal monitoring, and gaps in national and local guidance and staff training on monitoring and managing suspected chorioamnionitis in pre-term pregnancies.

    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 specific guidance for identifying and treating chorioamnionitis in pre-term mothers

    Wider context from the report

    “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place. 2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring. 3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular: 4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future. ”

    Source location

    Nola-Reign Morgan · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. West London

    AI-generated summary

    Thomas Hoskin · 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

    Thomas Hoskin was born by forceps at West Middlesex University Hospital on 8 April 2019 after signs of acute infection during labour. His condition at birth was extremely poor, and despite resuscitation he died in hospital shortly after birth on 9 April 2019. The report identified a lack of specific guidelines for managing fetal infection, which can be fatal or life-changing, as a substantive concern.

    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 specific guidelines for the optimal management of fetal infection

    Wider context from the report

    “It was brought to the Court's attention that the focus of guidelines relate to maternal infection, which is rarely life-threatening, but not to the optimal management of fetal infection which can be fatal or life changing. For Thomas, the evolving infection caused fetal circulatory collapse at birth and he could not be resuscitated. There appear to be no specific guidelines available to assist clinicians in this difficult situation and it was agreed by the independently instructed expert and the clinicians who gave evidence that this would be a helpful development. ”

    Source location

    Thomas Hoskin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Worcestershire

    AI-generated summary

    RHIAN EMMA KATE ROSE · 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

    Rhian Rose became unwell during a hospital admission for the second phase of medical termination of pregnancy following feticide for trisomy 21. Her condition deteriorated, leading to emergency caesarean section, hysterectomy and cardiac arrest; she died from multi-organ failure and sepsis on 25 November 2019. The principal concerns were insufficient consideration of informed consent and maternal choice regarding mode of delivery, and inadequate guidance on infection risks and delivery options following feticide.

    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 specific guidance for managing infection risk following feticide

    Wider context from the report

    “2) Infection risk of retained foetus following feticide – I am concerned that a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical discussions when a mother is attending for delivery (following feticide). There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach. Cases such as Rhian’s may well be rare, however consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide. ”

    Source location

    RHIAN EMMA KATE ROSE · 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

    Amend local guidelines to require prompt sepsis-bundle activation and avoid attributing maternal temperature solely to misoprostol.

    Verbatim wording from the response

    “Retention of a dead fetus also poses a significant risk of infection, therefore in combination Rhian was at high risk of infection and this does not appear to have been documented.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 4 · response
    Published 4 November 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

    Review fetal-loss guidance to reflect updated induction guidance and the additional infection risk following feticide.

    Verbatim wording from the response

    “Induction of Labour guidance has recently been updated by NICE NG207 published 4th November 2021. In response to this WHAT are reviewing the fetal loss local guidance to reflect these changes and to highlight the additional risk of infection when feticide has been performed prior to delivery.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 4 · response
    Published 4 November 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

    Further guidance on delivery following feticide should ideally come from a national body or a tertiary unit where feticide is performed.

    Verbatim wording from the response

    “There is no national guidance on delivery following feticide; as such there is no local guidance. Following this tragic incident we engaged with the regional Chief Midwife and learnt of a similar case which had occurred in a separate maternity unit. In light of this information, the obstetric lead at WAHT has been in contact with the regional Obstetric lead. If guidance is needed for management of delivery following feticide this would ideally come from a National body (eg RCOG) or from a tertiary unit where feticide is performed. We are happy to share our learning from this case and to contribute to national guidance on this matter.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 4 · response
    Published 4 November 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

    Current induction-of-labour guidance, implemented amendments and shared learning are considered sufficient pending any regional or national guidance.

    Verbatim wording from the response

    “There are no ongoing actions within the trust for this recommendation. Possible national or regional guidance would be adopted if available. We currently manage labour following feticide according to our ‘Induction of Labour’ guideline. Within the trust, amendments and improvements to induction guidelines have already been implemented and learning from this case has already been shared widely. We will fully engage with any regional or national guideline formation.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 6 · response
    Published 4 November 2021

    Open published response
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Data last updated 7 September 2026