Recurring concern

Unreliable major haemorrhage response arrangements

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First reported 21 Jul 2015•Latest report 13 Dec 2024

Definition

What this concern includes

Includes failures in the dedicated major-haemorrhage response process, including recognition and activation thresholds, protocol and pathway operation, access to blood products and urgent testing, staffing, equipment, communication, escalation and assurance of the response across relevant clinical settings.

Not included

Excludes general bleeding-management deficiencies where no major-haemorrhage response process is identified.
Excludes routine blood-product storage, transfusion or laboratory delays unrelated to an activated or potentially indicated major-haemorrhage response.
Excludes obstetric, trauma or other condition-specific care failures where the major-haemorrhage response process is not the deficient control.
Excludes failures occurring after a major-haemorrhage response has operated reliably when the remaining issue is unrelated downstream treatment.

Reports: 5
Individual concerns: 5
Date range: 2015–2024
Stated actions: 5

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.

Aneurin Bevan University LHB1

Betsi Cadwaladr University LHB1

Department of Health and Social Care1

Mid and South Essex NHS Foundation Trust1

Royal College of Obstetricians and Gynaecologists1

University Hospitals Birmingham NHS Foundation Trust1

University Hospitals of Derby and Burton NHS Foundation Trust1

Welsh Government1

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.

13 Dec2024
Essex
Concerns raised1
1. Failure to trigger the major haemorrhage protocol
This report raised 15 other concerns. 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 3
1. Action
  Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
2. Action
  Provide guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
3. Action
  Address major-haemorrhage protocol compliance through education, training, amended guidance and monthly monitoring.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
AI-generated summary

LAURA-JANE KIRSTEN NICOLE SEAMAN · 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

Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.

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 trigger the major haemorrhage protocol
Wider context from the report
“(1) The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023 c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts d. Communication issues with Trust staff and sharing of information e. Lack of compliance with national guidance and training f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient g. Lack of compliance with the triggering of the major haemorrhage protocol ”
Source location
LAURA-JANE KIRSTEN NICOLE SEAMAN · 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
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.

Verbatim wording from the response
“The RCOG’s clinical guidance in this context includes the following:”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 18 December 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 guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.

Verbatim wording from the response
“5. Good Practice Paper on Roles and responsibilities of the consultant providing acute care in obstetrics and gynaecology⁹ states that one of the general situations in which the consultant must attend is any return to theatre for obstetrics or gynaecology. Some of the other obstetrics reasons for attendance are early warning score protocol or sepsis screening tool that suggests critical deterioration where HDU / ITU care is likely to become necessary or maternal collapse or where ‘major obstetric haemorrhage’ call has been instigated.”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 4 · response
Published 18 December 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
Address major-haemorrhage protocol compliance through education, training, amended guidance and monthly monitoring.

Verbatim wording from the response
“Although this concern was not specifically drawn out in the initial Rapid Review, the HSIB report highlighted this as a safety action which has now been addressed through education, training, and the amendment of local guidance.”

Source location
Response from Mid & South Essex NHS Trust
Page 6 · response
Published 18 December 2024
Open published response
14 May2024
Birmingham and Solihull
Concerns raised1
1. Delays in obtaining blood products after major haemorrhage protocol activation
This report raised 2 other concerns. 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 1
1. Action
  Audit compliance with the Major Haemorrhage Blood Protocol across all UHB sites.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated in progress
Respondent positions 2
1. Position
  A blood fridge is not being provided because group O blood is nationally scarce and Heartlands is not a Major Trauma Centre.
  Stated by University Hospitals Birmingham NHS Foundation TrustUnable to act
1. Position
  The blood arrived within 15 minutes after major haemorrhage protocol activation, so the relevant delay was in requesting blood and activating the protocol.
  Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concern
AI-generated summary

James Patrick PEARSON · 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

James Pearson was struck by a vehicle on 14 June 2023 and later died at a hospice on 22 October 2023 after sustaining traumatic and hypoxic brain injuries, developing pneumonia, and experiencing a prolonged hospital admission. The concerns included undocumented observations, insufficient doctor coverage during his deterioration, and the time needed to obtain blood products; the report also states that an opportunity to provide fluids was missed and that this would probably have prevented his cardiac arrest and subsequent hypoxic brain injury.

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
Delays in obtaining blood products after major haemorrhage protocol activation
Wider context from the report
“9. I further heard from ████████ that the blood products at Birmingham Heartlands Hospital are not kept in the ED, and are kept some distance away, and could take up to 20 minutes to obtain after the major haemorrhage protocol is activated. Whilst this is unlikely to have affected the outcome for James, due to his sudden deterioration, I am concerned that a delay in obtaining blood products could lead to future deaths. ”
Source location
James Patrick PEARSON · 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
Audit compliance with the Major Haemorrhage Blood Protocol across all UHB sites.

Verbatim wording from the response
“A review of all incidents involving activation of the MHP within Heartlands Emergency Department since Mr Pearson’s death has been undertaken. This did not demonstrate any incidents regarding delays in receipt of blood once the MHP was activated. A full audit is underway by the Hospital Transfusion Group to review overall compliance to the Major Haemorrhage Blood Protocol across all UHB sites, the outcome of this will be reported to the Trust Transfusion Committee.”

Source location
Response from University Hospitals Birmingham
Page 3 · response
Published 20 May 2024
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 blood fridge is not being provided because group O blood is nationally scarce and Heartlands is not a Major Trauma Centre.

Verbatim wording from the response
“The recommendation to consider a blood fridge in BHH ED has been discussed in the Hospital Transfusion team. There are significant consequences to putting a fridge in the ED at BHH, not least that group O blood (which is what would need to be in the fridge if it is being used to support immediate transfusion) is in short supply nationally and needs to be used only for those patients that require it. This includes not stocking it in locations where it is unlikely to be used, which includes EDs (such as Heartlands) which are not in Major Trauma Centres.”

Source location
Response from University Hospitals Birmingham
Page 3 · response
Published 20 May 2024
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 blood arrived within 15 minutes after major haemorrhage protocol activation, so the relevant delay was in requesting blood and activating the protocol.

Verbatim wording from the response
“Availability of blood products within the emergency department You heard evidence that it can take up to 20 minutes to obtain blood products within the emergency department following activation of the major haemorrhage protocol. Whilst this delay was unlikely to have affected the outcome for Mr Pearson, you are concerned that delays in blood products being available could result in future deaths.”

Source location
Response from University Hospitals Birmingham
Page 3 · response
Published 20 May 2024
Open published response
18 Dec2023
North Wales (East and Central)
Concerns raised1
1. Lack of clarity about when to engage the Major Haemorrhage Pathway
This report raised 11 other concerns. 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 1
1. Action
  Display the Major Haemorrhage Pathway in all clinical areas, including the Emergency Department resuscitation area.
  Stated by Betsi Cadwaladr University LHBStated completed
Respondent positions 1
1. Position
  The Major Haemorrhage Pathway is available to all staff, visibly displayed, and supported by experienced senior staff.
  Stated by Betsi Cadwaladr University LHBExisting arrangements considered sufficient
AI-generated summary

Vivienne Greener · 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

Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.

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 clarity about when to engage the Major Haemorrhage Pathway
Wider context from the report
“5. There is not a clear understanding of when the Major Haemorrhage Pathway should be engaged; ”
Source location
Vivienne Greener · Prevention of Future Deaths report
Page 4 · 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
Display the Major Haemorrhage Pathway in all clinical areas, including the Emergency Department resuscitation area.

Verbatim wording from the response
“Any member of staff can trigger the Major Haemorrhage Pathway and it is printed on the wall in all clinical areas, including the resuscitation area in ED, and is clearly visible to all. Senior staff who are all very familiar with the pathway are always available and support all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the pathway.”

Source location
Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 2023
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 Major Haemorrhage Pathway is available to all staff, visibly displayed, and supported by experienced senior staff.

Verbatim wording from the response
“Any member of staff can trigger the Major Haemorrhage Pathway and it is printed on the wall in all clinical areas, including the resuscitation area in ED, and is clearly visible to all. Senior staff who are all very familiar with the pathway are always available and support all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the pathway.”

Source location
Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 2023
Open published response
16 Mar2023
Derby and Derbyshire
Concerns raised1
1. Failure to test the procedure for calling and responding to a major maternal haemorrhage
This report raised 2 other concerns. 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Rachael Chloe WALKER · 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

Rachael Chloe Walker died in hospital on 19 June 2021 after a placental haemorrhage and amniotic fluid embolism at 37 weeks of pregnancy. The report identified missed opportunities involving the recording and implementation of an earlier delivery plan and national guidance. The principal concern was whether the Trust had sufficiently robust processes for updating clinical guidance and ensuring essential equipment and procedures were in place.

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 test the procedure for calling and responding to a major maternal haemorrhage
Wider context from the report
“My principal concern is that having heard evidence from the Trust as to ‘lessons learnt’ and its current processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, I remain unclear that the Trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of Chloe. Indeed, I am unclear that the processes are substantively different to those that existed at the time of Chloe’s death. It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into Trust policy and guidance. I was told that introducing revised guidance was necessarily complex and lengthy and yet the Trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the Trust had established a regional pregnancy service using out of date guidance. Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process; for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest. I therefore consider that the Trust should review its processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the interests of preventing future deaths, and that those processes should ensure timely revisions and associated actions. ”
Source location
Rachael Chloe WALKER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jul2015
Gwent
Concerns raised1
1. Major obstetric haemorrhage protocol failing to meet published clinical guidelines
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Rachel Hollister · 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

Rachel Hollister died after suffering a cardiac arrest during surgery for removal of a retained placenta following childbirth at the Royal Gwent Hospital on 13 April 2013. Concerns included staff and porters not following or being unaware of Health Board protocols, and the major obstetric haemorrhage protocol not meeting published guidelines.

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
Major obstetric haemorrhage protocol failing to meet published clinical guidelines
Wider context from the report
“2. The major obstetric haemorrhage protocol does not meet the guidelines published by the Royal College of Obstetricians and Gynaecologists ”
Source location
Rachel Hollister · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to trigger the major haemorrhage protocol

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.3

Concerns raised1

Delays in obtaining blood products after major haemorrhage protocol activation

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.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of clarity about when to engage the Major Haemorrhage Pathway

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.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to test the procedure for calling and responding to a major maternal haemorrhage

Concerns raised1

Major obstetric haemorrhage protocol failing to meet published clinical guidelines

Actions described in response 3

Actions described in response 1

Respondent positions 2

Actions described in response 1

Respondent positions 1