Recurring concern

Unreliable communication and coordination across maternity care providers

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First reported 16 Jul 2015•Latest report 5 Aug 2025

Definition

What this concern includes

Includes failures of communication, referral, specialist involvement, information exchange or coordination between providers involved in maternity care, including antenatal providers and obstetric involvement in emergency or post-natal care.

Not included

Excludes generic inter-agency communication or coordination failures without an explicit maternity-care connection.
Excludes failures limited to clinical assessment, treatment, staffing or documentation where maternity-provider communication or coordination is not the unsafe condition.
Excludes non-maternity communication between healthcare providers, including general mental-health, prison-healthcare or other service interfaces.
Excludes failures involving pregnancy or birth risk assessment itself when the communication or coordination between maternity providers is not materially deficient.

Reports: 15
Individual concerns: 17
Date range: 2015–2025
Stated actions: 20

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.

Department of Health and Social Care5

NHS England2

Airedale NHS Foundation Trust1

Ashford and St Peter'S Hospitals NHS Foundation Trust1

Care Quality Commission1

Cheltenham General Hospital1

General Medical Council1

Gloucestershire Hospitals NHS Foundation Trust1

Health Services Safety Investigations Body1

London Ambulance Service NHS Trust1

Mid Cheshire Hospitals NHS Foundation Trust1

Musgrove Park Hospital1

Portsmouth Hospitals University NHS Trust1

Royal Berkshire NHS Foundation Trust1

Royal College of Obstetricians and Gynaecologists1

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.

27 Nov2017
Portsmouth and South East Hampshire
Concerns raised1
1. Failure of the emergency information-relay system between birthing centres and hospitals
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 2
1. Action
  Update the Standard Operating Procedure and Clinical Directive to require clinicians to identify time-critical transfers and prioritise qualifying inter-facility calls as Category 1.
  Stated by South Central Ambulance Service NHS Foundation TrustStated completed
2. Action
  Issue a reminder to Emergency Departments and birthing units across the South Central area about the process for requesting time-critical transfers.
  Stated by South Central Ambulance Service NHS Foundation TrustStated planned
AI-generated summary

Rafe Robbie Angelo · 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

Rafe Robbie Angelo was born at 17:30 on 23 September 2014 after his mother was transferred from the Blake Birthing Centre to hospital during labour. He was born pale and floppy, without breathing or a heart rate, and died after 37 minutes of resuscitation. The principal concerns included delays in recognising the need for urgent delivery and communication failures between the birthing centre, ambulance service and hospital, including failure to request a time-critical transfer and a non-urgent ambulance stop.

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 emergency information-relay system between birthing centres and hospitals
Wider context from the report
“This was a critical part of this case and as such needs further consideration of both the past and current systems and whether appropriate training has been given; whether it is currently working; and whether refresher training is needed. ”
Source location
Rafe Robbie Angelo · 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
Update the Standard Operating Procedure and Clinical Directive to require clinicians to identify time-critical transfers and prioritise qualifying inter-facility calls as Category 1.

Verbatim wording from the response
“Following your report, we have reviewed the SOP and updated it so that any Health Care Professional (HCP) requesting an Inter-facility transfer (i.e. Hospital or Birthing Unit) who asks for an emergency / immediate response will now be asked “Do you require a Time Critical Transfer?” Due to the known risks associated with obstetric emergencies. Midwives will be asked whether the case is time critical when they call from a patient’s home as well as a standalone birthing centre. If the HCP answers positively then the Emergency Call Taker (ECT) will prioritise the call using the TCT pathway and will process the call as a Category 1 response.”

Source location
2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 1 · response
Published 27 February 2018
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
Issue a reminder to Emergency Departments and birthing units across the South Central area about the process for requesting time-critical transfers.

Verbatim wording from the response
“The new Standard Operating Procedure and Clinical Directive has been sent to all staff in the Emergency Operations Centre. A mail drop will also be issued to all Emergency Departments and Birthing units across the South Central Area to remind all HCP’s of the correct process to request a Time critical transfer.”

Source location
2017-0421-Response-by-South-Central-Ambulance-Service-NHS-Trust
Page 1 · response
Published 27 February 2018
Open published response
1 Jun2016
Surrey
Concerns raised1
1. Failure to provide timely obstetric consultant supervision after emergency admission
This report raised 6 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
  Implement daily consultant review of patients on Joan Booker Ward, with labour ward consultant cover when usual consultants are unavailable.
  Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completed
AI-generated summary

Rhi anne Anoushka Florence BARTON · 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

Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.

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 timely obstetric consultant supervision after emergency admission
Wider context from the report
“1. Rhi anne’s named obstetric consultant was not informed of her emergency admission. Although there was a consultant obstetrician on the ward on the 11th February there was no request for Rhi anne to be seen and in any event it was not common practice for patients to be seen by another consultant. As such there was no obstetric consultant supervision of Rhi anne from the time of admission until shortly before her surgery; approximately 43 hours after admission. ”
Source location
Rhi anne Anoushka Florence BARTON · 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 daily consultant review of patients on Joan Booker Ward, with labour ward consultant cover when usual consultants are unavailable.

Verbatim wording from the response
“We have actioned a change in Consultant working practices to facilitate timely review of patients on Joan Booker Ward. The default planning is that Consultants will review patients under their care every working day; where other commitments or absences preclude this, and at weekends, the labour ward Consultant will review the patients. This pattern of working has been in place since March 2015. I have included as Appendix 1, the details of this working pattern.”

Source location
2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
Page 1 · response
Published 1 June 2016
Open published response
25 Feb2016
Liverpool and the Wirral
Concerns raised1
1. Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services
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

Amy Rose COOPER · 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

Amy was born at 40 weeks’ gestation by caesarean section on 8 July 2015 and required immediate resuscitation before being confirmed dead later that evening. Intrauterine growth restriction was not evident to the community midwives or hospital maternity unit until post-mortem investigations; the report also raised concerns about incompatible record-keeping systems and the sharing of maternity information between services.

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 compatible digital record-keeping and medical note systems enabling information sharing between maternity services
Wider context from the report
“It was clear at the inquest that maternity services which had been commissioned in this region had not been required to have a specification for record keeping, notes and scans which could be digitally available to other maternity services operating in the same area. Such that Arrowe Park Hospital needed to have the paper notes from One to One North West Ltd. to ensure continuity of care. This does not appear to be the most efficient system for continuity of patient care and could have been remedied by the commissioners of the services requiring compatible record keeping and medical note systems to ensure the easy sharing of information. This would also enable community based midwives to refer a patient to a consultant without the patient necessarily having to attend the maternity unit in the first place. Further access to notes would make the admission to the maternity unit safer and seamless, delivering what should be a better patient experience and outcome. ”
Source location
Amy Rose COOPER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Oct2015
Gloucestershire
Concerns raised2
1. Failure to involve the obstetric department in Emergency Department care for post-natal patients
2. Lack of a process for sharing information and joining up care between community and obstetric providers
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

Samantha Beach · 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

Samantha Beach developed severe chest pain and intermittent tachycardia shortly after giving birth to her third child, but her symptoms were not appropriately investigated or escalated. She later suffered cardiac arrests and died after surgery for bleeding from a ruptured splenic artery aneurysm. Concerns included inadequate escalation of care, poor sharing of information between community and hospital services, and failure to involve the obstetric department when she attended the Emergency Department.

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 involve the obstetric department in Emergency Department care for post-natal patients
Wider context from the report
“(3) When Sam attended the Emergency Department as a post-natal patient (7 days post partum) the obstetric department were not involved in her care. ”
Source location
Samantha Beach · 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 a process for sharing information and joining up care between community and obstetric providers
Wider context from the report
“(2) When Sam was being cared for in the community, there was no process to ensure the sharing of information or joining up of care between the midwives, out of hours, GP and obstetric department. ”
Source location
Samantha Beach · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Jul2015
South Yorkshire (Eastern)
Concerns raised1
1. Failure to maintain effective communication links between ante-natal healthcare providers
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

Isabella Rosa Drew · 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

Isabella Rosa Drew was a 29-day-old infant who contracted whooping cough in early September 2014 and died on 9 September 2014; the recorded causes of death were severe acute pneumonia and Bordetella pertussis. The report raised concerns that pregnant women were not consistently offered whooping cough vaccination, and that national guidance did not provide sufficient detail on local procedures, auditing, follow-up, and communication between antenatal healthcare providers.

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 maintain effective communication links between ante-natal healthcare providers
Wider context from the report
“(2) a need for further national guidance regarding the importance of effective communication links between the various limbs of ante-natal healthcare providers. ”
Source location
Isabella Rosa Drew · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of the emergency information-relay system between birthing centres and hospitals

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

Concerns raised1

Failure to provide timely obstetric consultant supervision after emergency admission

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

Concerns raised1

Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services

Concerns raised2

Failure to involve the obstetric department in Emergency Department care for post-natal patients

Lack of a process for sharing information and joining up care between community and obstetric providers

Concerns raised1

Failure to maintain effective communication links between ante-natal healthcare providers

Actions described in response 2

Actions described in response 1