Recurring concern

Unsafe feticide and post-feticide care

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First reported 28 Jul 2014•Latest report 3 Nov 2021

Definition

What this concern includes

Includes failures in the dedicated feticide and post-feticide care process, including clinically appropriate feticide decisions and timing, sensitive and understandable information for parents, management of infection and retained fetal remains, delivery planning, specialist advice and multidisciplinary coordination.

Not included

Excludes general abortion, termination-of-pregnancy or maternity-care deficiencies where feticide or post-feticide care is not the material safety concern.
Excludes generic communication or information deficiencies unless they directly concern explaining the feticide process to parents or communicating its associated risks and decisions.
Excludes routine neonatal or maternal care after the feticide-related process has been safely completed, unless the reported deficiency remains part of post-feticide management.
Excludes unrelated fetal-loss, premature-labour and bereavement concerns without a direct feticide or post-feticide care connection.

Reports: 3
Individual concerns: 4
Date range: 2014–2021
Stated actions: 2

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 Care1

Manchester University NHS Foundation Trust1

North Devon District Hospital1

Royal College of Obstetricians and Gynaecologists1

Worcestershire Acute Hospitals NHS Trust1

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.

3 Nov2021
Worcestershire
Concerns raised2
1. Failure to give due weight to infection risk from retained foetus in delivery discussions following feticide
2. Lack of specific guidance for managing infection risk following feticide
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review fetal-loss guidance to reflect updated induction guidance and the additional infection risk following feticide.
  Stated by Worcestershire Acute NHS TrustStated in progress
2. Action
  Amend local guidelines to require prompt sepsis-bundle activation and avoid attributing maternal temperature solely to misoprostol.
  Stated by Worcestershire Acute NHS TrustStated completed
Respondent positions 2
1. Position
  Further guidance on delivery following feticide should ideally come from a national body or a tertiary unit where feticide is performed.
  Stated by Worcestershire Acute NHS TrustRedirects responsibility
1. Position
  Current induction-of-labour guidance, implemented amendments and shared learning are considered sufficient pending any regional or national guidance.
  Stated by Worcestershire Acute NHS TrustExisting arrangements considered sufficient
AI-generated summary

RHIAN EMMA KATE ROSE · 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

Rhian Rose became unwell during a hospital admission for the second phase of medical termination of pregnancy following feticide for trisomy 21. Her condition deteriorated, leading to emergency caesarean section, hysterectomy and cardiac arrest; she died from multi-organ failure and sepsis on 25 November 2019. The principal concerns were insufficient consideration of informed consent and maternal choice regarding mode of delivery, and inadequate guidance on infection risks and delivery options following feticide.

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 give due weight to infection risk from retained foetus in delivery discussions following feticide
Wider context from the report
“2) Infection risk of retained foetus following feticide – I am concerned that a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical discussions when a mother is attending for delivery (following feticide). There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach. Cases such as Rhian’s may well be rare, however consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide. ”
Source location
RHIAN EMMA KATE ROSE · 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 specific guidance for managing infection risk following feticide
Wider context from the report
“2) Infection risk of retained foetus following feticide – I am concerned that a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical discussions when a mother is attending for delivery (following feticide). There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach. Cases such as Rhian’s may well be rare, however consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide. ”
Source location
RHIAN EMMA KATE ROSE · 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
Review fetal-loss guidance to reflect updated induction guidance and the additional infection risk following feticide.

Verbatim wording from the response
“Induction of Labour guidance has recently been updated by NICE NG207 published 4th November 2021. In response to this WHAT are reviewing the fetal loss local guidance to reflect these changes and to highlight the additional risk of infection when feticide has been performed prior to delivery.”

Source location
2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
Page 4 · response
Published 4 November 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
Amend local guidelines to require prompt sepsis-bundle activation and avoid attributing maternal temperature solely to misoprostol.

Verbatim wording from the response
“Retention of a dead fetus also poses a significant risk of infection, therefore in combination Rhian was at high risk of infection and this does not appear to have been documented.”

Source location
2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
Page 4 · response
Published 4 November 2021
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
Further guidance on delivery following feticide should ideally come from a national body or a tertiary unit where feticide is performed.

Verbatim wording from the response
“There is no national guidance on delivery following feticide; as such there is no local guidance. Following this tragic incident we engaged with the regional Chief Midwife and learnt of a similar case which had occurred in a separate maternity unit. In light of this information, the obstetric lead at WAHT has been in contact with the regional Obstetric lead. If guidance is needed for management of delivery following feticide this would ideally come from a National body (eg RCOG) or from a tertiary unit where feticide is performed. We are happy to share our learning from this case and to contribute to national guidance on this matter.”

Source location
2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
Page 4 · response
Published 4 November 2021
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
Current induction-of-labour guidance, implemented amendments and shared learning are considered sufficient pending any regional or national guidance.

Verbatim wording from the response
“There are no ongoing actions within the trust for this recommendation. Possible national or regional guidance would be adopted if available. We currently manage labour following feticide according to our ‘Induction of Labour’ guideline. Within the trust, amendments and improvements to induction guidelines have already been implemented and learning from this case has already been shared widely. We will fully engage with any regional or national guideline formation.”

Source location
2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
Page 6 · response
Published 4 November 2021
Open published response
18 Jul2018
Manchester (West)
Concerns raised1
1. Lack of a sensitive, lay-language leaflet fully explaining the feticide process to parents
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 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

Mohamed Rahman · 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 Mohamed Rahman was born at 01:45 on 17 February 2018 after an elective feticide procedure and was confirmed dead at 02:48 that day. The principal concerns were that fetal asystole was not unequivocally confirmed before discharge, that the mother and professionals were unprepared for the birth, and that documentation and guidance about confirming fetal demise and explaining the procedure to parents required consideration.

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 a sensitive, lay-language leaflet fully explaining the feticide process to parents
Wider context from the report
“4. Consideration should also be given to the desirability of a leaflet for parents which fully explains the feticide process using appropriately sensitive and lay terminology. ”
Source location
Mohamed Rahman · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Jul2014
Exeter & Greater Devon
Concerns raised1
1. Restriction of feticide use before induction of labour for late terminations until after the relevant gestational date
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

Faye Elizabeth RIPPON · 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

Faye Elizabeth RIPPON was delivered prematurely at 21 weeks’ gestation on 8 February 2014 at North Devon District Hospital following medical termination of pregnancy to save her mother’s life. The report raised concerns that a late termination resulted in a live birth, including the distress caused to the midwives and parents, and noted that a similar case had recently occurred.

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
Restriction of feticide use before induction of labour for late terminations until after the relevant gestational date
Wider context from the report
“(1) I write to express concerns that in this case performance of late terminations of pregnancy i.e. 21/40 gestation resulted in a live birth. I am aware your protocols for the use of a feticide BEFORE induction of labour only allow foeticide to be used after this gestational date. However, I believe the Abortion Act was amended specifically to avoid the problems posed with late terminations resulting in live births. (2)It is extremely distressing for the midwives caring for the mother to be presented with a live baby which is not to receive life-saving medical attention, not to mention the lasting damage to the psyche of the parents. (3)A similar case arose at Inquest in the Royal Devon and Exeter Hospital only six days ago so live birth post induction of labour for termination of pregnancy is not an isolated occurrence. ”
Source location
Faye Elizabeth RIPPON · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to give due weight to infection risk from retained foetus in delivery discussions following feticide

Lack of specific guidance for managing infection risk following feticide

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

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

Concerns raised1

Lack of a sensitive, lay-language leaflet fully explaining the feticide process to parents

Concerns raised1

Restriction of feticide use before induction of labour for late terminations until after the relevant gestational date

Actions described in response 2

Respondent positions 2