Recurring concern

Inadequate controls for uterine rupture risks after prior uterine surgery

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First reported 30 Jun 2014•Latest report 10 Sep 2025

Definition

What this concern includes

Includes controls specifically dedicated to preventing, recognising or communicating uterine rupture risks associated with prior caesarean section or other uterine surgery, including contraindication checks before administering cervical-ripening agents such as Propess and accurate, complete information for patients considering VBAC.

Not included

  • Excludes general induction-of-labour, mode-of-delivery or maternity risk-assessment deficiencies where uterine rupture after prior uterine surgery is not the material safety condition.
  • Excludes general medication-prescribing or administration failures where Propess or uterine-rupture risk is not involved.
  • Excludes generic informed-consent or patient-information deficiencies that do not concern uterine rupture risk after prior uterine surgery.
  • Excludes management of an established uterine rupture after the relevant risk-control process has operated adequately.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
3

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.

Great Western Hospitals NHS Foundation Trust1
Royal College of Obstetricians and Gynaecologists1
Southend University Hospital1

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. Avon

    AI-generated summary

    Mabel Olivia Williams · 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

    Mabel Olivia Williams was born alive after a trial of vaginal birth after caesarean section and died six days later in a neonatal intensive care unit following severe hypoxic-ischaemic encephalopathy associated with an undiagnosed uterine rupture. The concerns included inadequate information and informed consent about the risks of uterine rupture, failures to recognise or communicate signs of distress in time, and delays in making appropriate changes after serious clinical incidents.

    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 provide complete information about uterine rupture and its consequences in patient guidance

    Wider context from the report

    “Background The Ockenden Report, which I was directed to in evidence, first published in 2020 a list of immediate and essential actions which included: ‘all Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.’ The externally conducted HSIB report which looked into Mabel’s death identified in February 2024 that the Trust’s guidance for patients on ‘Birth after caesarean’ did not describe what a uterine rupture is. That point was made in the context of Mabel’s parents telling the HSIB investigation that they were not informed about the possible consequences of a uterine scar rupture, or that at their most severe those consequences could include the death of their baby. I found at the conclusion of Mabel’s inquest that appropriate steps had not been taken to obtain ████████ informed consent to VBAC, and the shortcomings of the Trust’s patient information leaflets were part of what informed that finding. In advance of the inquest the Trust’s legal representatives found it difficult to provide me with current copies of relevant patient information leaflets. When they were finally disclosed (on day 3 of the inquest) I found it hard to get a clear picture of whether the leaflets were or were not ‘in force’. I heard evidence at one point from a member of trust staff that revised leaflets (which did contain a full explanation of uterine rupture) had been drafted but not signed off by the Trust for distribution to patients, much to the frustration of the maternity unit. I was also provided with an Excel spreadsheet after the inquest which contained, among other things, information about the Trust’s compliance with various objectives relating to the Ockenden Review. The information in that spreadsheet included an indication that one of the Trust’s objective was that “Change in practice arising from an SI investigation must be seen within 6 months after the incident occurred”. The spreadsheet suggested that this objective was not being achieved. This would accord with my impression (which I would have reached irrespective of having sight of the spreadsheet) that much of the change that I was being shown following Mabel’s death was coming very late, and as a response to the impending (or active) inquest, not as a result of learning from the tragic events in question. Specific concern That the Trust may not be making appropriate changes within a reasonable timeframe following serious clinical incidents. ”

    Source location

    Mabel Olivia Williams · 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

    Revise and provide the Birth After Previous Caesarean leaflet with clear uterine-rupture risks during birth-options counselling.

    Verbatim wording from the response

    “The Trust has undertaken a comprehensive review of the “Birth After Previous Caesarean” patient information leaflet. The revised leaflet now provides a clear, accessible explanation of uterine rupture, including its potential severity and the associated risks to both mother and baby which includes the risk of the death of the baby.”

    Source location

    Response from Great Western Hospitals NHS Foundation Trust
    Page 1 · response
    Published 16 September 2025

    Open published response

  2. Avon

    AI-generated summary

    Mabel Olivia Williams · 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

    Mabel Olivia Williams suffered a fatal hypoxic injury during a trial of vaginal birth after caesarean section and died six days later in a neonatal intensive care unit in Bristol. The report identified concerns that information about VBAC did not explain that uterine rupture could be fatal, and that indicators of Mabel’s distress and her mother’s worsening condition were not recognised or conveyed in time to expedite her birth safely.

    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 VBAC information to identify that uterine rupture can be fatal

    Wider context from the report

    “When ████████ was advised about VBAC she was referred to internal guidance from the hospital and to the RCOG’s information leaflet “Birth options after previous caesarean section” (published in July 2016). I reviewed the information leaflet and it does not contain any indication that uterine rupture could potentially prove fatal for mother and / or baby. My concern is that prospective parents may rely on this information leaflet to assist them in making informed choices about their birth options, and that if the risk is not identified then other patients like ████████ might pursue VBAC in circumstances where – if they had understood the risk better – they would have chosen otherwise. ”

    Source location

    Mabel Olivia Williams · 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

    Review and update the RCOG patient information leaflet on birth after previous caesarean.

    Verbatim wording from the response

    “This RCOG leaflet has been reviewed and updated recently and is due for publication in the very near future.”

    Source location

    Response Royal College of Obstetricians & Gynaecologists
    Page 3 · response
    Published 16 September 2025

    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

    Publish the recently reviewed and updated RCOG patient information leaflet.

    Verbatim wording from the response

    “This RCOG leaflet has been reviewed and updated recently and is due for publication in the very near future.”

    Source location

    Response Royal College of Obstetricians & Gynaecologists
    Page 3 · response
    Published 16 September 2025

    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 leaflet identifies uterine rupture risks and serious consequences, including stillbirth, although it does not use the word “fatal”.

    Verbatim wording from the response

    “The patient information leaflet Birth after Previous Caesarean², while not using the precise term ‘fatal’ in relation to uterine rupture nonetheless states the risks and that stillbirth can be a serious consequence of VBAC.”

    Source location

    Response Royal College of Obstetricians & Gynaecologists
    Page 2 · response
    Published 16 September 2025

    Open published response

  3. Essex

    AI-generated summary

    Jessica Hope Bond · 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

    Jessica Hope Bond suffered significant brain injury following a uterine rupture during her mother's labour, which necessitated an emergency caesarean section, and she died seven months later. The report raises concern that Propess should not be administered to patients with a history of previous caesarean section or uterine surgery because of the potential risk of uterine rupture and associated obstetrical complications.

    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

    Risk of uterine rupture and associated obstetrical complications from Propess use in patients with previous caesarean section or uterine surgery

    Wider context from the report

    “(1) Independent expert opinion has drawn attention to the fact that Propess should not be administered to patients with a history of previous caesarean section or uterine surgery given the potential risk for uterine rupture and associated obstetrical complications. Uterine rupture has been reported in association with the use of Propess ”

    Source location

    Jessica Hope Bond · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026