Concerns raised 1
Lack of adequate communication between healthcare professionals on the maternity unit View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Daisy May McCoy · 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
Daisy May McCoy was born by Caesarean section on 9 February 2022 after reduced and unusual foetal movement was reported, and died in a children’s hospice on 22 February 2022 following a brain injury and peri-natal asphyxia. The report identified concerns about recognising foetal compromise, communication and escalation between staff, staffing and consultant attendance, professional challenge, and the adequacy and implementation of relevant policies and training.
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 adequate communication between healthcare professionals on the maternity unit
Wider context from the report “7. A lack of adequate communication between different health care professionals on the maternity unit .
” Source location Daisy May McCoy · Prevention of Future Deaths report
Open source report
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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 Extend centralised CTG monitoring and formal SBAR handovers across both acute maternity sites, including antenatal monitoring.
Verbatim wording from the response “• Implementation of Centralised CTG monitoring” Source location Response from Somerset NHS Foundation Trust
Open published response
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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 Introduce standardised SBAR handovers and safety huddles for multidisciplinary communication.
Verbatim wording from the response “In addition to efforts described above, the Trust has introduced the use of standardised handover and safety huddle “SBAR” (Situation, Background, Assessment, Recommendation tool for structured handover information sharing) to provide an infrastructure for communication events between different health care professionals. The Trust has also recently engaged the national Equity Diversity and Inclusion lead to undertake a culture review diagnostic. The results of this review are pending, and the Trust will work with the national team to inform continued efforts to improve culture across SFT maternity services.” Source location Response from Somerset NHS Foundation Trust
Open published response
2 Dec 2024 Alfie HINTON · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1
Failure of communication between consultant obstetric and anaesthetic staff in time critical situations View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Airedale NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Airedale NHS Foundation Trust
Strengthen the anaesthesia guideline for Category 1 caesarean sections, including five-minute multidisciplinary review and conversion to general anaesthesia where appropriate.
View source
Airedale NHS Foundation Trust
Create and publish a Category 1 caesarean section and fetal bradycardia process map covering escalation, anaesthetic decisions, effective anaesthesia and delivery timelines.
View source
Airedale NHS Foundation Trust
Embed multidisciplinary PROMPT training for anaesthetists, obstetricians and midwives using an evidence-based human-factors approach.
View source
Airedale NHS Foundation Trust
Embed simulation-based training using obstetric emergencies, incidents, case reviews and patient experience to improve emergency teamwork and learning.
View source
Airedale NHS Foundation Trust
Develop Human Factors and Ergonomics Training Workshops led by a consultant anaesthetist to address systems and behavioural influences on outcomes.
View source See 2 more actions
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AI-generated summary
Alfie HINTON · 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
Baby Alfie Hinton died at Airedale Hospital on 10 May 2019 after complete umbilical cord occlusion led to hypoxic ischaemic brain injury. The report describes delays in induction, fetal monitoring, recognition of bradycardia and preparations for birth. Concerns included how maternal risk information was gathered, recorded and communicated, communication between consultants, and the absence of local policy for time-critical situations.
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 communication between consultant obstetric and anaesthetic staff in time critical situations
Wider context from the report “(2) During the course of the Inquest, I heard evidence about the difficulties in communication between the Consultant Obstetrician and Consultant Anaesthetist , with delays being caused by several attempts being made at sitting spinal anaesthetic, against the advice of the Obstetrician and the wishes of the patient, causing distress to staff and patient alike. I heard no evidence of any policy that provided direction or guidance in circumstances such as this.
This gives rise to concerns in respect of communication , ongoing risk assessment and an absence of local policy in respect of the approach to be taken in such time critical situations.
” Source location Alfie HINTON · Prevention of Future Deaths report
Open source report
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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 Strengthen the anaesthesia guideline for Category 1 caesarean sections, including five-minute multidisciplinary review and conversion to general anaesthesia where appropriate.
Verbatim wording from the response “The Guideline was revised post Alfie’s case (March 2020 and again in October 2023) and the relevant sections (taken from the version created in October 2023) state:” Source location Response from Airedale NHS Foundation Trust
Open published response
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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 Create and publish a Category 1 caesarean section and fetal bradycardia process map covering escalation, anaesthetic decisions, effective anaesthesia and delivery timelines.
Verbatim wording from the response “Process – Category 1 Caesarean Section / Fetal Bradycardia” Source location Response from Airedale NHS Foundation Trust
Open published response
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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 Embed multidisciplinary PROMPT training for anaesthetists, obstetricians and midwives using an evidence-based human-factors approach.
Verbatim wording from the response “As part of an organic development in health practice but also designed specifically to address the issues which occurred in this present case, particularly focussed on culture, leadership, team working and compliance with national standards, the Trust undertook the following:” Source location Response from Airedale NHS Foundation Trust
Open published response
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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 Embed simulation-based training using obstetric emergencies, incidents, case reviews and patient experience to improve emergency teamwork and learning.
Verbatim wording from the response “3. As explained in evidence to the Inquest, the Trust has embedded SIMS training – real life Simulation Based Training which is based on obstetric emergencies and scenarios. This is a learning tool used to improve team working in emergency procedures. The SIMS training includes learning from scenarios, incidents, case reviews, patients’ experience and themes and trends across the service to improve learning and reflection. This facilitates constructive feedback to aid teams working together, learning from scenarios and dynamic integration into current themes on the maternity unit.” Source location Response from Airedale NHS Foundation Trust
Open published response
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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 Develop Human Factors and Ergonomics Training Workshops led by a consultant anaesthetist to address systems and behavioural influences on outcomes.
Verbatim wording from the response “6. As explained in evidence to the Inquest, the Trust has developed a programme of Human Factor and Ergonomics Training Workshops, led by a Consultant Anaesthetist, which focuses on systems issues within healthcare and how human behaviours influence outcome and can be modified through systems changes to achieve better clinical outcomes (the principles of such training are explained at Human factors | NHS England | Workforce, training and education).” Source location Response from Airedale NHS Foundation Trust
Open published response
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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 Existing records, handovers, ward rounds, SBAR communication and coordinator oversight were relied upon to communicate risk and prioritise inductions.
Verbatim wording from the response “As to the specific issue of how risk factors are communicated, every expectant mother admitted to the maternity unit would be under the care of an obstetric consultant and/or midwife and those clinicians would bear responsibility for knowing the patient’s history and presentation and to review and complete the patient’s record, which would contain all such information.” Source location Response from Airedale NHS Foundation Trust
Open published response
14 Mar 2024 Zachary Victor TAYLOR-SMITH · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1
Persisting relationship and communication problems between maternity and neonatal staff View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals of Derby and Burton NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
University Hospitals of Derby and Burton NHS Foundation Trust
Run the Culture and Civility improvement project and track its action plan through programme governance.
View source
University Hospitals of Derby and Burton NHS Foundation Trust
Publish and socialise the Culture and Civility workshop outputs and charter.
View source
University Hospitals of Derby and Burton NHS Foundation Trust
Expand Team of the Shift huddles to include neonatal team members.
View source
University Hospitals of Derby and Burton NHS Foundation Trust
Implement a midwife-led junior doctor induction session on roles, relationships and supportive teamwork.
View source See 1 more action
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AI-generated summary
Zachary Victor TAYLOR-SMITH · 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
Zachary Taylor-Smith was born preterm after an induced labour and died aged 14 hours at Royal Derby Hospital on 17 November 2022. The inquest found that he contracted an infection and that his death was contributed to by neglect, including failures relating to prophylactic antibiotics, recognition of the duration since rupture of membranes, and treatment of signs of early-onset infection. Concerns included staff understanding of infection indicators, communication between maternity and neonatal teams, systems for ensuring reviews were completed, and the safety of planned inductions given service capacity.
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 Persisting relationship and communication problems between maternity and neonatal staff
Wider context from the report “c. The persisting cultural issues affecting the relationships and communication between maternity and neonatal staff . Given that the responsibility for checking and monitoring signs of infection in the newborn was not, from the evidence, placed on either the midwifery team or the neonatologists but was a joint one, the relationship that exists between the teams is of critical importance .
” Source location Zachary Victor TAYLOR-SMITH · Prevention of Future Deaths report
Open source report
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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 Run the Culture and Civility improvement project and track its action plan through programme governance.
Verbatim wording from the response “• Culture and civility” Source location Response from University Hospitals of Derby and Burton
Open published response
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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 and socialise the Culture and Civility workshop outputs and charter.
Verbatim wording from the response “The Culture & Civility Work Programme hosted two Culture and Civility workshops with places offered to clinical staff in March 2024. The outputs from these workshops included 'what good culture looks like to me' and a good culture and civility charter. These are in the process of being published and socialised to the teams.” Source location Response from University Hospitals of Derby and Burton
Open published response
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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 Expand Team of the Shift huddles to include neonatal team members.
Verbatim wording from the response “• Safety huddles” Source location Response from University Hospitals of Derby and Burton
Open published response
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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 a midwife-led junior doctor induction session on roles, relationships and supportive teamwork.
Verbatim wording from the response “• Junior doctor induction” Source location Response from University Hospitals of Derby and Burton
Open published response
30 Jun 2023 Sinon MASHA · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Failure to involve patients’ named obstetric consultants in multiprofessional appointments View source Fragmented communication between professionals involved in birth-choice planning View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Birmingham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
University Hospitals Birmingham NHS Foundation Trust
Hold biweekly multidisciplinary meetings for joint discussion and planning with the named consultant.
View source
University Hospitals Birmingham NHS Foundation Trust
Audit multidisciplinary input for high-risk home births to evidence consultant involvement in birth plans.
View source
University Hospitals Birmingham NHS Foundation Trust
Allocate a consultant to regular multidisciplinary meetings following completion of consultant job planning.
View source
University Hospitals Birmingham NHS Foundation Trust
Review and align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.
View source See 1 more action
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AI-generated summary
Sinon MASHA · 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
Sinon Masha was born at home on 17 December 2021 following a breech presentation that was not identified until labour. After a 27-minute delay before delivery of his head, he suffered a catastrophic hypoxic brain injury and died on 21 December 2021. The principal concern was that the Trust’s process for managing home births against medical advice was not operating as set out in its guidance, was fragmented, and might result in insufficiently informed birth choices that put lives at risk.
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 patients’ named obstetric consultants in multiprofessional appointments
Wider context from the report “2. Specifically, Section 5 of the Birth Choices Guidance include:
“5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices.
...
5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged.
5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated.
5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.”
3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all . Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk.
4. Evidence was given by the Director of Midwifery that although patient’s named Consultants are not involved in multiprofessional appointments with the patient there is a bi-weekly meeting of the other professionals who discuss all high risk patients and then the Consultant midwife meets with the patient’s named Consultant (who will have reviewed the patient in clinic) and discusses the individual cases and the birth plans. This system is felt to be working satisfactorily by the Consultant midwife.
5. I remain concerned that the current approach has evolved from necessity rather than being a carefully considered and planned amendment to the Trust’s guidance. Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding. This system also deprives the patient of the benefit of hearing the perspectives of all the relevant professionals together in a setting where they, the patient, can witness the discussion and be satisfied that everyone has considered all the relevant factors and answered any queries or concerns they may have relevant to their decision. Consequently, I am concerned that patients may not be making fully informed decisions resulting in birth choices that put lives at risk.
” Source location Sinon MASHA · Prevention of Future Deaths report
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 Fragmented communication between professionals involved in birth-choice planning
Wider context from the report “2. Specifically, Section 5 of the Birth Choices Guidance include:
“5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices.
...
5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged.
5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated.
5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.”
3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all. Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk.
4. Evidence was given by the Director of Midwifery that although patient’s named Consultants are not involved in multiprofessional appointments with the patient there is a bi-weekly meeting of the other professionals who discuss all high risk patients and then the Consultant midwife meets with the patient’s named Consultant (who will have reviewed the patient in clinic) and discusses the individual cases and the birth plans. This system is felt to be working satisfactorily by the Consultant midwife.
5. I remain concerned that the current approach has evolved from necessity rather than being a carefully considered and planned amendment to the Trust’s guidance. Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding . This system also deprives the patient of the benefit of hearing the perspectives of all the relevant professionals together in a setting where they, the patient, can witness the discussion and be satisfied that everyone has considered all the relevant factors and answered any queries or concerns they may have relevant to their decision. Consequently, I am concerned that patients may not be making fully informed decisions resulting in birth choices that put lives at risk.
” Source location Sinon MASHA · Prevention of Future Deaths report
Open source report
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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 Hold biweekly multidisciplinary meetings for joint discussion and planning with the named consultant.
Verbatim wording from the response “• A Bi-weekly MDT meeting is in place with joint discussion and planning separately with the named consultant.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
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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 multidisciplinary input for high-risk home births to evidence consultant involvement in birth plans.
Verbatim wording from the response “• To ensure compliance with the standards an audit is in place to evidence multidisciplinary input for high-risk home births. The initial audit has demonstrated that for those women who had requested birth outside of guidance, there was always consultant input into their birth plan.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
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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 Allocate a consultant to regular multidisciplinary meetings following completion of consultant job planning.
Verbatim wording from the response “• There is a plan to agree allocated Consultant (either Delivery suite lead or Antenatal clinic lead) to regular MDT meetings. This is contingent on the current consultant job planning (due for completion by 31 August 2023). Following job planning this action will be completed before the 31 October 2023.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
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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 align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.
Verbatim wording from the response “• A review of the Birth Choices Guidelines (CG1200) and the home birth guidance (CG1143) is being undertaken and will be completed by 31 October 2023. Currently there are discrepancies in relation to the referral pathway, roles and responsibilities of members of the multi-professional team (including Consultant Midwife), and inclusion of the woman in birth planning discussions. Alignment of these guidelines will provide a clear and standardised pathway for referral and management for women/birthing people requesting birth outside of guidance including homebirth, and clarity of Roles and responsibilities of each member for the Multi professional team.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
15 Feb 2023 Raniya Rizwan Khan · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Failure to maintain the system for communicating relevant paediatric admissions and deterioration to maternity staff View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Royal Berkshire Hospital
Implement a process to store all placentas for 48 hours, identify those requiring histology, and send them for examination before disposal.
View source
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AI-generated summary
Raniya Rizwan Khan · 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
Raniya Rizwan Khan was born on 9 May 2020 and died at Great Ormond Street Hospital on 28 May 2020 after her condition deteriorated; the recorded cause of death was multi-organ failure and severe arterial pulmonary hypertension of unknown cause. Concerns included failures in labour monitoring and escalation by an agency midwife, and the reported non-completion of trust undertakings concerning placenta retention, related procedures and staff training.
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 the system for communicating relevant paediatric admissions and deterioration to maternity staff
Wider context from the report “It was surprising in the extreme to be made aware in open court on the final day of this inquest that these undertakings have not in fact been completed – the system referred to above is not in place , there is no SOP, nor has there been any staff training. It was particularly disappointing to hear this in front of a family who had themselves lost a baby and who were being reassured of how committed the trust is to improvement.
” Source location Raniya Rizwan Khan · Prevention of Future Deaths report
Open source report
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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 a process to store all placentas for 48 hours, identify those requiring histology, and send them for examination before disposal.
Verbatim wording from the response “Following the regulation 28 report sent to the trust on 20th June 2022 actions were taken to enable a robust process for sending placentas for histological examination. This included a process to ensure the storage of all placentas for 48 hours from the time of birth. The Standard Operating Procedure (MATSOP064) detailing these changes was ratified at the maternity clinical governance meeting on 7th October 2022.” Source location Response from Royal Berkshire NHS Foundation Trust
Open published response
18 Mar 2022 Remi Nana KODUAH · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1
Failure to colocate the resuscitation area with the operating theatre for effective obstetric-neonatal communications View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Remi Nana KODUAH · 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
Remi Nana KODUAH was born at Leighton Hospital on 22 November 2018 and died shortly afterwards following ruptured vasa praevia and severe blood loss. The substantive concerns were that the resuscitation area was separate from the operating theatre, affecting communication, and that neonatal and adult bloods were not kept in the resuscitation room.
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 colocate the resuscitation area with the operating theatre for effective obstetric-neonatal communications
Wider context from the report “(1) That the resuscitation area was separate to the operating theatre thus hampering effective communications between the obstetric team and the neonatal team .
(2) Neonatal bloods and adult bloods are not kept in the resuscitation room. Since Baby Remi’s death bloods have been moved to the labour ward which is 2 mins away but in time critical moments this may still be too far away.
” Source location Remi Nana KODUAH · Prevention of Future Deaths report
Open source report
19 Sep 2019 Caspian Thorn · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of communication between midwifery and social work teams View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Caspian Thorn · 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
Caspian Thorn was born with significant brain damage after chronic placental insufficiency and died in hospital on 29 September 2018 after developing a gram-negative hospital-acquired infection and sepsis. The concerns included failure to offer induction or follow up a missed growth scan, poor communication and support for a vulnerable family, undocumented triage calls, inadequate documentation of decision-making, delayed recognition of a pathological CTG, and delayed recognition of signs of sepsis.
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 communication between midwifery and social work teams
Wider context from the report “1. A feature of the evidence was a lack of communication between the teams of midwives and social worker . This meant that it was not picked up that his mother had missed a key fetal growth scan and that a small baby was not monitored for the period between 10th September until his birth on 24th September. The inquest heard that contributing to this was a shortage of midwives in the enhanced midwifery team and a shortage of experienced social workers in the Local Authority at the time;
” Source location Caspian Thorn · Prevention of Future Deaths report
Open source report
31 Jul 2019 Fern-Marie CHOYA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to involve the obstetric team in the assessment and management of pregnant emergencies View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Fern-Marie CHOYA · 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
Fern-Marie Choya died from hypovolaemic shock caused by massive intra-abdominal bleeding following rupture of the abdominal gravid uterus during a monochorionic diamniotic pregnancy. Concerns included failure to communicate her pregnancy during the pre-hospital alert and on hospital arrival, a 16-minute delay in recognising the pregnancy and calling the obstetric team, and treatment focused on possible pulmonary embolism before free fluid was identified.
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 team in the assessment and management of pregnant emergencies
Wider context from the report “3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya.
” Source location Fern-Marie CHOYA · Prevention of Future Deaths report
Open source report
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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 Launch criteria for initiating an obstetric call before a patient's arrival, jointly agreed by obstetric and emergency teams.
Verbatim wording from the response “2. A set of criteria have been developed to determine if an obstetric call needs to be initiated prior to patient arrival. The Trust already has a process in place for trauma calls, which has now been expanded to cover obstetric callout criteria. In agreeing the criteria, advice was sought from Emergency Department colleagues in other trusts to see if similar systems were already in place and the final criteria were agreed jointly with our obstetrics and emergency teams. The new criteria have now been launched in the Emergency Department. A copy of the criteria is included in Appendix B.” Source location 2019-0281-Resposne-by-Whittington-Health-NHS-Trust
Open published response
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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 emergency department’s treatment decisions are the Whittington Hospital’s responsibility, although LAS measures may support more timely future care.
Verbatim wording from the response “3. Without the obstetric team, the emergency department team focus was on the potential for a pulmonary embolism, and alteplase was given. Only later was a scan conducted and free fluid noted. By the time of the laparotomy it was too late to save Ms Choya.” Source location 2019-0281-Resposne-by-London-Ambulance-Service
Open published response
23 Jan 2019 Gail Bailey · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1
Failure to forewarn obstetric and gynaecology clinicians of emergency arrivals View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Gail Bailey · 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
Gail Bailey, who was nine weeks pregnant, developed abdominal discomfort while on holiday on 5 August 2017. An ambulance was called but arrived after a delay, and she was declared deceased at Boston Pilgrim Hospital later that evening. The report raised concerns about emergency communication and preparedness, including pre-alert calls that were not dated or signed and the apparent lack of advance warning to obstetric and gynaecology staff.
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 forewarn obstetric and gynaecology clinicians of emergency arrivals
Wider context from the report “C) I received evidence from Mr Bailey that upon arrival at hospital the clinicians appeared not to be ready for his wife's arrival.
D) I received evidence from Mr ████████, consultant in the Accident and Emergency Unit at Boston Pilgrim Hospital, that ████████, a Specialty Doctor in Emergency medicine present at the time had noted in the medical records that he, together with other doctors had attempted to resuscitate Mrs Bailey who had presented to A & E in a collapsed state around 21.00 hours and had noted that "a cardiac arrest call-out had also been initiated in or around the time of the patients' arrival to Pilgrim."
E) I received evidence from the locum registrar for the labour ward, ████████ that "[My understanding at that time was that] no Obstetrician and gynaecologist was forewarned about this patients arrival to the A & E department. "
F) The ED records confirmed that two pre alert calls were recorded but not dated nor signed.
G) Whilst the severity of Mrs Bailey's condition meant that in the particular circumstances of this case the treatment Mrs Bailey received at hospital neither caused nor contributed to her death, the apparent breakdown in communication does raise an area of concern in relation to future emergency admissions.
” Source location Gail Bailey · Prevention of Future Deaths report
Open source report
9 Oct 2018 Alba May Pemberton · Prevention of Future Deaths report North London
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Concerns raised 1
Lack of MDT meetings between obstetric and midwifery staff View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Alba May Pemberton · 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
Alba May Pemberton was born on 10 August 2016 after experiencing hypoxia during the active second stage of delivery and lived for two days. The report identified delayed five-minute heart monitoring and the possible absence of earlier CTG monitoring as concerns, noting that earlier detection and delivery might have resulted in survival. Concerns also included the classification of meconium, use of CTG equipment, obstetric review at birthing centres, and closer multidisciplinary working.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of MDT meetings between obstetric and midwifery staff
Wider context from the report “There should be MDT meetings with the obstetric staff and midwifery staff and obstetric staff encouraged to work closely together in the management of low risk cases.
” Source location Alba May Pemberton · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.