Recurring concern

Unreliable terminology in obstetric delivery guidance and decisions

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First reported 31 Mar 2015•Latest report 30 Apr 2026

Definition

What this concern includes

Includes failures in terminology, definitions or wording used in obstetric delivery guidance, protocols, records or decision communication where the ambiguity or misleading phrasing can obscure clinical risk, the safety status of delivery, or when a procedure should continue, change or stop.

Not included

  • Excludes general clinical terminology, communication or documentation deficiencies without an obstetric delivery context.
  • Excludes substantive gaps, outdated content or conflicting requirements in obstetric guidance where terminology clarity is not the shared unsafe condition.
  • Excludes maternity risk-assessment and mode-of-delivery decision failures where the applicable terminology is clear and the deficiency lies in clinical judgement or implementation.
  • Excludes terminology problems in mental-health, policing, ambulance, product or other non-obstetric systems unless the assertion directly concerns the same obstetric delivery terminology process.
Reports
4

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
9

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.

Department of Health and Social Care3
National Institute for Health and Care Excellence2
NHS England2
Royal College of Obstetricians and Gynaecologists2
Homerton Healthcare NHS Foundation Trust1
Nursing and Midwifery Council1
Pennine Acute Hospitals NHS Trust1
Royal College of Midwives1

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. North London

    AI-generated summary

    Poppy Hope LOMAS · 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

    Poppy Hope LOMAS died in hospital on 26 October 2022, aged 7 days, after being born in poor condition following a home delivery. The report describes multiple unrecognised risk factors during the delivery and identifies concerns about consent and risk communication, multidisciplinary review, terminology used for unsafe deliveries, and the absence of a maternal pulse oximeter from the home delivery kit.

    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

    Use of terminology failing to convey the gravity and unsafe nature of delivery against medical advice

    Wider context from the report

    “It is a matter of concern that the nationally used expression “Out of Guidance” is used in these circumstances, which may fail to convey the gravity of the decisions being taken, rather than an expression that captures all elements:- in particular that the delivery is against medical advice, the Royal College of Obstetricians and Gynaecologists guidance and that as a consequence it is an unsafe delivery. ”

    Source location

    Poppy Hope LOMAS · 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

    Set minimum standards for safe homebirth services, including clear terminology, safety and risk assessment, multidisciplinary care planning, consent documentation, and standardised equipment.

    Verbatim wording from the response

    “By autumn 2026, we anticipate setting out the minimum standards that providers and commissioners of maternity services will be expected to meet to support the delivery of a safe, effective, equitable and personalised home birth service. The standards will include the use of appropriate and clear language in discussing women’s preferences, including review of the term “Out of Guidance”. The standards will also include detail on the assessment of safety and risk required, and the need for multi-disciplinary team working in the formulation of care plans and their documentation. This will also include consideration of the use of consent forms which are not currently used in maternity services for any place of birth. It will also include reference to the standardised equipment required for clinical care provided during homebirth.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 10 July 2026

    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

    Amendments to NICE guidance language are not appropriate because the terminology reflects sensitivity around paternalism and patient choice.

    Verbatim wording from the response

    “The National Institute for Health and Care Excellence (NICE) has considered the comments made regarding the term 'birth outside of guidance'. This term has been chosen carefully to reflect the sensitivities around discussions where women have felt in the past that their care has been paternalistic and choice has been removed, and we therefore do not feel that amendments to the language within NICE guidance are appropriate.”

    Source location

    Response from National Institute for Health and Care Excellence
    Page 2 · response
    Published 10 July 2026

    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

    NICE cannot recommend expressions used by NHS staff because wording must remain case relevant and part of professional skill.

    Verbatim wording from the response

    “NICE is unable to make recommendations on expressions used by NHS staff as these should be case relevant and part of a professional skill set.”

    Source location

    Response from National Institute for Health and Care Excellence
    Page 2 · response
    Published 10 July 2026

    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

    Responsibility for the specific homebirth concerns sits with NHS England, which will issue the substantive response.

    Verbatim wording from the response

    “In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns, and I understand there is work underway to develop national standards and a clear framework for homebirth services. As responsibility for the specific matters of concern you have raised sits with NHS England, they will be issuing a substantive response addressing each of these concerns.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 10 July 2026

    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

    NHS Trusts are responsible for ensuring midwives and obstetricians practise in line with relevant maternity guidance.

    Verbatim wording from the response

    “Trusts are responsible for ensuring midwives and obstetricians practice in line with this guidance and the new homebirth standards will take these documents into account to ensure greater clarity and alignment of advice across all organisations.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 10 July 2026

    Open published response

  2. Manchester North

    AI-generated summary

    Jennifer Cahill and Agnes Cahill · 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

    Jennifer Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.

    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

    Use of pregnancy terminology that obscures stage-specific risk

    Wider context from the report

    “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child. Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth. ”

    Source location

    Jennifer Cahill and Agnes Cahill · 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

    Contribute to the task and finish group on national homebirth guidance, frameworks, ethical proportionality, informed risk discussions, maternal risks, terminology and training needs.

    Verbatim wording from the response

    “As the professional regulator for midwives in the UK, the NMC plans to play an active role in the group in line with our regulatory role. More specifically, we propose to take the following actions in response to the matters of concern detailed in your report as follows:”

    Source location

    Response from Nursing & Midwifery Council
    Page 4 · response
    Published 7 November 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

    Review guidance to consider defining high- and low-risk pregnancy and distinguishing pregnancy risks from labour and birth risks.

    Verbatim wording from the response

    “There is a discussion about this in the final scope (the final scope defines what the guideline will and will not cover and to whom it will apply) for intrapartum care for women with existing medical conditions or obstetric complications and their babies (NG121). It defines a high risk pregnancy: “A pregnancy is ‘high risk’ when the likelihood of an adverse outcome for the woman or the baby is greater than that of the ‘normal population’. A labour is ‘high risk’ when adverse outcomes arise in association with labour.””

    Source location

    Response from National Institute for Health and Care Excellence
    Page 4 · response
    Published 7 November 2025

    Open published response

  3. Inner North London

    AI-generated summary

    Ziggy Dylan MITCHELL-STAGG · 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

    Ziggy was born by emergency Caesarean section at Homerton University Hospital on 3 April 2021 in a very compromised state and died a few hours later. The concerns included inconsistent terminology for meconium, a lack of a medical-record entry by the attending obstetric registrar after 3.46am, no local policy on centralised CTG monitoring, and a trust policy providing for fresh-eyes reviews every two hours rather than the hourly national guidance.

    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 standardised terminology for describing meconium

    Wider context from the report

    “1. There was not standardisation of the terminology used by the midwives and obstetricians to describe the meconium found, and the information requested by the computer system to record this did not necessarily reflect the verbal descriptions. Sometimes grades I, II & III were used; sometimes significant & insignificant; sometimes thick or thin. There was also inconsistency as to whether grade II was significant, and whether the term significant referred purely to the meconium noted, or to the meconium in the context of other features. ”

    Source location

    Ziggy Dylan MITCHELL-STAGG · 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

    Implement the approved meconium grading-system upgrade, including clinician prompts to record rationale and required escalation.

    Verbatim wording from the response

    “a) Our computer system upgrade was already in place before the inquest, and one of the upgrades included updating the meconium grading from Grade I, II & III to the new system of Significant and Insignificant. The Trust has approved this change. A text box will now flash up once significant/insignificant is selected that will allow the clinician to enter the reason why they made that selection and when any onward action/escalation is needed. This change has been finalised and will be implemented by March 2022.”

    Source location

    2021-0425-Homerton-University-Hospital_Published
    Page 1 · response
    Published 22 December 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

    Update and circulate maternity policies to replace Grade I–III meconium terminology with significant/insignificant terminology.

    Verbatim wording from the response

    “b) As stated above, the Trust acknowledges that the grading of meconium is not up to date and is inconsistent. We therefore plan to hold a ‘Meconium Awareness Month’ where the following will happen:-”

    Source location

    2021-0425-Homerton-University-Hospital_Published
    Page 1 · response
    Published 22 December 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

    Deliver specific staff training on identifying significant or insignificant meconium and using the new terminology in communication and records.

    Verbatim wording from the response

    “b) As stated above, the Trust acknowledges that the grading of meconium is not up to date and is inconsistent. We therefore plan to hold a ‘Meconium Awareness Month’ where the following will happen:-”

    Source location

    2021-0425-Homerton-University-Hospital_Published
    Page 1 · response
    Published 22 December 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

    Use daily safety huddles and handovers to remind staff about the revised meconium terminology and related changes.

    Verbatim wording from the response

    “• daily safety huddles and handovers will ensure that staff are reminded of this change and will be encouraged to take time to review all the changes;”

    Source location

    2021-0425-Homerton-University-Hospital_Published
    Page 2 · response
    Published 22 December 2021

    Open published response

  4. Manchester North

    AI-generated summary

    Thomas Beaty · 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 Beaty was born by emergency caesarean section after an abandoned instrumental delivery on 11 April 2014. At 26 hours of age, he suffered a catastrophic head injury, hypovolaemic shock and hypoxic brain ischaemia, and died. The report raised concerns that guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, including unclear terminology and misleading guidance about traction.

    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

    Use of misleading and clinically inappropriate ‘gentle’ traction terminology

    Wider context from the report

    “1. Instrumental Delivery – the Court heard how local/national protocols and training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘…When to abandon the procedure: • No evidence of progressive descent with each pull • No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator…’ The first point by implication must mean that where there is no descent with the first pull, then the procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction. 2. Terminology - The RCOG Guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery. 3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with. 4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the Guidance issued by the RCOG. ”

    Source location

    Thomas Beaty · 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

    Lack of operational definitions for instrumental-delivery terminology

    Wider context from the report

    “1. Instrumental Delivery – the Court heard how local/national protocols and training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘…When to abandon the procedure: • No evidence of progressive descent with each pull • No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator…’ The first point by implication must mean that where there is no descent with the first pull, then the procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction. 2. Terminology - The RCOG Guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery. 3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with. 4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the Guidance issued by the RCOG. ”

    Source location

    Thomas Beaty · 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

    Ambiguity in guidance on when to abandon instrumental delivery

    Wider context from the report

    “1. Instrumental Delivery – the Court heard how local/national protocols and training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘…When to abandon the procedure: • No evidence of progressive descent with each pull • No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator…’ The first point by implication must mean that where there is no descent with the first pull, then the procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction. 2. Terminology - The RCOG Guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery. 3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with. 4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the Guidance issued by the RCOG. ”

    Source location

    Thomas Beaty · 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

    Revise and ratify the assisted vaginal delivery guideline with clarified consultant presence, abandonment criteria, terminology and traction requirements.

    Verbatim wording from the response

    “Instrumental Delivery Guidance Since the sad death of Thomas Beaty, the Trust reviewed and revised the Guideline for Assisted Vaginal Delivery in order to provide staff with greater clarity and guidance regarding the requirement for Consultant presence for trial in theatre if the operator is less than 5ft 6. Additional guidance was also added with regards to the flexion point, complications of instrumental deliveries, and disimpaction of the head. This guideline was ratified in December 2014.”

    Source location

    2015-0130-Response-by-Pennine-Acute-Hospitals
    Page 1 · response
    Published 31 March 2015

    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

    Send the coroner’s report to the RCOG to communicate the concerns about ambiguity in its maternity guidance.

    Verbatim wording from the response

    “You had a number of concerns about the guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG), which the inquest found to be ambiguous, misleading and potentially open to misinterpretation, giving as the example that the RCOG guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’.”

    Source location

    2015-0130-Response-by-Department-of-Health
    Page 1 · response
    Published 31 March 2015

    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

    Local maternity and neonatal providers are responsible for determining how services should be delivered in their areas.

    Verbatim wording from the response

    “While local maternity and neonatal care providers must determine how best to deliver services in their area, in doing so we would expect them to give due regard to RCOG and other professional guidance. To this end, a copy of your report has been sent to the RCOG to make them aware of the concerns you have raised and I understand that they have responded to you directly.”

    Source location

    2015-0130-Response-by-Department-of-Health
    Page 1 · response
    Published 31 March 2015

    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

    RCOG is responsible for addressing concerns about its professional guidance.

    Verbatim wording from the response

    “While local maternity and neonatal care providers must determine how best to deliver services in their area, in doing so we would expect them to give due regard to RCOG and other professional guidance. To this end, a copy of your report has been sent to the RCOG to make them aware of the concerns you have raised and I understand that they have responded to you directly.”

    Source location

    2015-0130-Response-by-Department-of-Health
    Page 1 · response
    Published 31 March 2015

    Open published response
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Data last updated 7 September 2026