Recurring concern

Unsafe management of antepartum haemorrhage

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First reported 2 Jul 2024•Latest report 22 Jul 2024

Definition

What this concern includes

Includes failures of controls specifically dedicated to antepartum-haemorrhage management, including recognition of vaginal bleeding as potentially serious, urgency guidance, assessment for occult blood loss, escalation, monitoring, senior involvement and timely intervention.

Not included

Excludes postpartum haemorrhage, general obstetric bleeding and other maternity emergencies unless the assertion specifically concerns antepartum haemorrhage.
Excludes generic midwifery staffing, training, communication or documentation deficiencies unless they directly impair antepartum-haemorrhage management.
Excludes fetal-monitoring, birth-planning and delivery-mode concerns where antepartum-haemorrhage management is not the unsafe condition.
Excludes failures occurring after an antepartum-haemorrhage response has been appropriately initiated when the deficiency concerns unrelated downstream care.

Reports: 2
Individual concerns: 4
Date range: 2024–2024
Stated actions: 8

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Sherwood Forest Hospitals NHS Foundation Trust2

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.

22 Jul2024
Nottinghamshire
Concerns raised3
1. Failure to treat bleeding in pregnancy as potentially serious until proven otherwise
2. Failure to follow established antepartum haemorrhage guidance
3. Failure to act promptly when women present with antepartum haemorrhage
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Update, ratify and disseminate the Antepartum Haemorrhage guideline, including immediate assessment, worst-case assumptions, telephone triage, escalation, and documentation requirements.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
2. Action
  Disseminate the RED React, Escalate, Diligent prompt cards and associated guidance on managing and escalating bleeding.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
3. Action
  Provide individualised support and training to staff who do not understand the amended guideline.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated planned
1. Action
  Continue multidisciplinary review of Antepartum Haemorrhage cases through the weekly Triggers meeting, escalating incidents and learning when required.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
2. Action
  Deliver and monitor mandatory training on BSOTS triage, BadgerNet documentation, cumulative blood-loss recording, and related PROMPT requirements.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated in progress
3. Action
  Develop and provide an Antepartum Haemorrhage scenario video demonstrating telephone triage and BSOTS assessment.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated in progress
AI-generated summary

Theodore Riley Bradley · 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

Theodore Riley Bradley was born on 14 September 2023 with no heart rate, breathing effort or movement after prolonged intrauterine hypoxia associated with a partial placental abruption. The report identifies a 37-minute delay before his mother was assessed at the maternity triage unit, and states that relevant maternity triage and antepartum haemorrhage policies were not followed. The principal concerns were a failure to respond promptly to vaginal bleeding in pregnancy and wider concerns about the management of antepartum haemorrhage.

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 treat bleeding in pregnancy as potentially serious until proven otherwise
Wider context from the report
“1, The lack of prompt action when a woman presents with an antepartum haemorrhage (APH). This Inquest revealed a culture within the midwifery team of not acting promptly when there is vaginal bleeding in pregnancy. There was an assumption that there was a benign cause for bleeding, rather than assuming, until proven otherwise that there is a serious cause, such as an abruption, that may require immediate intervention. Well established APH Trust guidance was not followed I set out that difficulty in effectively managing APH is also an accepted issue, for the neighbouring NUH NHS Trust , who are currently reviewing their guidance, and approach to managing APH. It is clearly a regional issue and may be a national one. I am not reassured that necessary actions to address these serious issues identified are in place. ”
Source location
Theodore Riley Bradley · Prevention of Future Deaths report
Page 2 · 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 follow established antepartum haemorrhage guidance
Wider context from the report
“1, The lack of prompt action when a woman presents with an antepartum haemorrhage (APH). This Inquest revealed a culture within the midwifery team of not acting promptly when there is vaginal bleeding in pregnancy. There was an assumption that there was a benign cause for bleeding, rather than assuming, until proven otherwise that there is a serious cause, such as an abruption, that may require immediate intervention. Well established APH Trust guidance was not followed I set out that difficulty in effectively managing APH is also an accepted issue, for the neighbouring NUH NHS Trust , who are currently reviewing their guidance, and approach to managing APH. It is clearly a regional issue and may be a national one. I am not reassured that necessary actions to address these serious issues identified are in place. ”
Source location
Theodore Riley Bradley · Prevention of Future Deaths report
Page 2 · 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 act promptly when women present with antepartum haemorrhage
Wider context from the report
“1, The lack of prompt action when a woman presents with an antepartum haemorrhage (APH). This Inquest revealed a culture within the midwifery team of not acting promptly when there is vaginal bleeding in pregnancy. There was an assumption that there was a benign cause for bleeding, rather than assuming, until proven otherwise that there is a serious cause, such as an abruption, that may require immediate intervention. Well established APH Trust guidance was not followed I set out that difficulty in effectively managing APH is also an accepted issue, for the neighbouring NUH NHS Trust , who are currently reviewing their guidance, and approach to managing APH. It is clearly a regional issue and may be a national one. I am not reassured that necessary actions to address these serious issues identified are in place. ”
Source location
Theodore Riley Bradley · 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
Update, ratify and disseminate the Antepartum Haemorrhage guideline, including immediate assessment, worst-case assumptions, telephone triage, escalation, and documentation requirements.

Verbatim wording from the response
“The Trust has reviewed and updated its Antepartum Haemorrhage (APH) guideline to emphasise the clinical importance of bleeding in pregnancy, and the requirement for an immediate assessment of fetal and maternal condition with any degree of bleeding. The guideline now informs staff that best practice is to treat bleeding with an expectation of a worse-case scenario and then de-escalate if appropriate, rather than treating it as benign. A telephone assessment section has been included within the Antepartum Haemorrhage guideline. This includes the need to consider transfer into hospital by ambulance and highlights the need to prepare the midwifery coordinator and obstetric staff in preparation for an incoming admission.”

Source location
Narrative Response from Sherwood Forest Hospitals
Page 1 · response
Published 1 August 2024
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
Disseminate the RED React, Escalate, Diligent prompt cards and associated guidance on managing and escalating bleeding.

Verbatim wording from the response
“An acronym has been developed within Trust, RED – React, Escalate, Diligent, with guidance next to each point on the expected management of bleeding. This includes reacting to the initial reported blood loss by advising attendance to triage and consideration of calling an ambulance. Escalating to the coordinating midwife, obstetric and triage staff that an attendance with bleeding is anticipated, and being diligent around the assessment of bleeding – preparing for an abnormality until proven otherwise. Prompt cards of the acronym have been disseminated to all clinical areas and shared via email to all staff members, and additional prompt card advising the potential causes of bleeding has been shared alongside this.”

Source location
Narrative Response from Sherwood Forest Hospitals
Page 2 · response
Published 1 August 2024
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
Provide individualised support and training to staff who do not understand the amended guideline.

Verbatim wording from the response
“The amended guideline received a multidisciplinary review including the obstetric service leads, midwifery matrons, and midwifery staff prior to ratification through the Maternity and Gynaecology Clinical Governance Meeting. Following ratification of the guideline, the updates have been shared with all staff members. The guideline updates have been shared via email and in person on shift handovers, and all staff have been asked to sign a registration sheet as evidence that they have read and understood the amendments. Additional support and training will be provided on an individualised basis to staff that do not understand the changes, this will be supported by their line manager and the practice development midwives.”

Source location
Narrative Response from Sherwood Forest Hospitals
Page 2 · response
Published 1 August 2024
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
Continue multidisciplinary review of Antepartum Haemorrhage cases through the weekly Triggers meeting, escalating incidents and learning when required.

Verbatim wording from the response
“Antepartum Haemorrhage cases will continue to be reviewed through our ‘triggers’ incident review meeting, to ensure that the recommendations within the updated guideline are being followed. ‘Triggers’ is a weekly multidisciplinary case review”

Source location
Narrative Response from Sherwood Forest Hospitals
Page 2 · response
Published 1 August 2024
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
Deliver and monitor mandatory training on BSOTS triage, BadgerNet documentation, cumulative blood-loss recording, and related PROMPT requirements.

Verbatim wording from the response
“A training programme has commenced focusing on the key areas of learning. This initially included refresher training for the core triage and Band 7 coordinating midwives on the Birmingham Symptom Specific Obstetric Triage System (BSOTS) BadgerNet (the Trusts Maternity electronic patient record) requirements. Delivered by the Trust’s Digital Midwife, the training including how to correctly document triage telephone calls within BadgerNet contemporaneously and how to utilise the ‘blood loss’ form correctly which in turn ensures any cumulative bleeding throughout pregnancy is captured. In addition, a BSOTS e-learning package has been mandated”

Source location
Narrative Response from Sherwood Forest Hospitals
Page 1 · response
Published 1 August 2024
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
Develop and provide an Antepartum Haemorrhage scenario video demonstrating telephone triage and BSOTS assessment.

Verbatim wording from the response
“The Maternity team are currently developing an Antepartum Haemorrhage scenario video that includes role play of a phone call in progress whilst a midwife completes the BSOTS telephone call proforma. This consists of a prompt and brief assessment (triage) of women when they present with unexpected problems or concerns, and then a standardised way of determining the clinical urgency and setting the time in which they need to be seen. This will be available for staff members to access anytime and has been included within our BSOTS Training Needs Analysis (TNA).”

Source location
Narrative Response from Sherwood Forest Hospitals
Page 2 · response
Published 1 August 2024
Open published response
2 Jul2024
Nottinghamshire
Concerns raised1
1. Failure of the Antepartum Haemorrhage guideline to convey urgency and account for occult blood loss
This report raised 1 other concern. 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 2
1. Action
  Update and ratify the Antepartum Haemorrhage guideline to require urgent assessment, worst-case assumptions, bleeding quantification, telephone triage, and preparation for potential ambulance transfer.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
2. Action
  Disseminate the ratified Antepartum Haemorrhage guideline changes to maternity staff through email and shift handovers, with read-and-understood acknowledgements.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
AI-generated summary

Arlo River Phoenix Lambert · 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

Arlo River Phoenix Lambert died aged 5 days after sustaining a hypoxic-ischaemic brain injury during the intrapartum period. The report describes multiple missed opportunities to deliver him earlier, alongside systemic failings in clinical guidance, escalation, communication and handover. Concerns included a lack of urgency in the Trust’s antepartum haemorrhage guideline and the absence of a clear system for obtaining early reflective accounts from key staff.

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 of the Antepartum Haemorrhage guideline to convey urgency and account for occult blood loss
Wider context from the report
“1. The Trust’s Antepartum Haemorrhage guideline gives no sense of urgency when staff are faced with a bleed – here, staff failed to appreciate the potential for a sinister cause of bleeding both at 21.18 and later at 03.40, and did not appear to appreciate the fact that a volume of the bleeding may well be occult, by the external volume representing only a small proportion of the actual blood loss. Miss Al-Samarrai accepted that further work was likely to be required in this regard. ”
Source location
Arlo River Phoenix Lambert · 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
Update and ratify the Antepartum Haemorrhage guideline to require urgent assessment, worst-case assumptions, bleeding quantification, telephone triage, and preparation for potential ambulance transfer.

Verbatim wording from the response
“The Trust has reviewed and updated its Antepartum Haemorrhage guideline to emphasise the clinical importance of bleeding in pregnancy, and the requirement for an immediate assessment of fetal and maternal condition with any degree of bleeding. The guideline now informs staff that best practice is to treat bleeding with an expectation of a worse-case scenario and then de-escalate if appropriate, rather than treating it as benign. The causes of Antepartum Haemorrhage section within the guideline has been amended to highlight that bleeding in pregnancy is not normal and can be unpredictable, and the expectation around quantifying and documenting repeated episodes of bleeding within the patient record has been added to support the ongoing risk assessments.”

Source location
Response from Sherwood Forest Hospitals NHS Trust
Page 1 · response
Published 4 July 2024
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
Disseminate the ratified Antepartum Haemorrhage guideline changes to maternity staff through email and shift handovers, with read-and-understood acknowledgements.

Verbatim wording from the response
“Following ratification of the guideline, the updates have been shared with all staff members. The guideline updates have been shared via email and in person on shift handovers, and all staff have been asked to sign a registration sheet as evidence that they have read and understood the amendments. Additional support and training will be provided on an individualised basis to staff that do not understand the changes, this will be supported by their line manager and the practice development midwives.”

Source location
Response from Sherwood Forest Hospitals NHS Trust
Page 1 · response
Published 4 July 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Failure to treat bleeding in pregnancy as potentially serious until proven otherwise

Failure to follow established antepartum haemorrhage guidance

Failure to act promptly when women present with antepartum haemorrhage

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.6

Concerns raised1

Failure of the Antepartum Haemorrhage guideline to convey urgency and account for occult blood loss

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

Actions described in response 6

Actions described in response 2