Recurring concern
Unreliable communication and coordination across maternity care providers
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Request correctionFirst reported 16 Jul 2015•Latest report 5 Aug 2025
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
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Lack of adequate communication between healthcare professionals on the maternity unit
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Extend centralised CTG monitoring and formal SBAR handovers across both acute maternity sites, including antenatal monitoring.
Stated by Somerset NHS Foundation Trust -
Action
Introduce standardised SBAR handovers and safety huddles for multidisciplinary communication.
Stated by Somerset NHS Foundation Trust
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Concerns raised1
Failure of communication between consultant obstetric and anaesthetic staff in time critical situations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.5
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Action
Strengthen the anaesthesia guideline for Category 1 caesarean sections, including five-minute multidisciplinary review and conversion to general anaesthesia where appropriate.
Stated by Airedale NHS Foundation Trust -
Action
Create and publish a Category 1 caesarean section and fetal bradycardia process map covering escalation, anaesthetic decisions, effective anaesthesia and delivery timelines.
Stated by Airedale NHS Foundation Trust -
Action
Embed multidisciplinary PROMPT training for anaesthetists, obstetricians and midwives using an evidence-based human-factors approach.
Stated by Airedale NHS Foundation Trust
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Action
Embed simulation-based training using obstetric emergencies, incidents, case reviews and patient experience to improve emergency teamwork and learning.
Stated by Airedale NHS Foundation Trust -
Action
Develop Human Factors and Ergonomics Training Workshops led by a consultant anaesthetist to address systems and behavioural influences on outcomes.
Stated by Airedale NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing records, handovers, ward rounds, SBAR communication and coordinator oversight were relied upon to communicate risk and prioritise inductions.
Stated by Airedale NHS Foundation Trust
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Concerns raised1
Persisting relationship and communication problems between maternity and neonatal staff
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.4
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Action
Run the Culture and Civility improvement project and track its action plan through programme governance.
Stated by University Hospitals of Derby and Burton NHS Foundation Trust -
Action
Publish and socialise the Culture and Civility workshop outputs and charter.
Stated by University Hospitals of Derby and Burton NHS Foundation Trust -
Action
Expand Team of the Shift huddles to include neonatal team members.
Stated by University Hospitals of Derby and Burton NHS Foundation Trust
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Action
Implement a midwife-led junior doctor induction session on roles, relationships and supportive teamwork.
Stated by University Hospitals of Derby and Burton NHS Foundation Trust
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Concerns raised2
Failure to involve patients’ named obstetric consultants in multiprofessional appointments
Fragmented communication between professionals involved in birth-choice planning
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 concernsEach statement is shown once, even when linked to more than one concern.
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.4
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Action
Hold biweekly multidisciplinary meetings for joint discussion and planning with the named consultant.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Audit multidisciplinary input for high-risk home births to evidence consultant involvement in birth plans.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Allocate a consultant to regular multidisciplinary meetings following completion of consultant job planning.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Action
Review and align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Concerns raised1
Failure to maintain the system for communicating relevant paediatric admissions and deterioration to maternity staff
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Implement a process to store all placentas for 48 hours, identify those requiring histology, and send them for examination before disposal.
Stated by Royal Berkshire Hospital
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Concerns raised1
Failure to colocate the resuscitation area with the operating theatre for effective obstetric-neonatal communications
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of communication between midwifery and social work teams
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to involve the obstetric team in the assessment and management of pregnant emergencies
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Launch criteria for initiating an obstetric call before a patient's arrival, jointly agreed by obstetric and emergency teams.
Stated by Whittington Health NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The emergency department’s treatment decisions are the Whittington Hospital’s responsibility, although LAS measures may support more timely future care.
Stated by London Ambulance Service NHS Trust
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Concerns raised1
Failure to forewarn obstetric and gynaecology clinicians of emergency arrivals
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of MDT meetings between obstetric and midwifery staff
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026