Recurring concern

Unreliable retention of biological samples for postmortem investigation

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First reported 20 Apr 2016•Latest report 25 Nov 2025

Definition

What this concern includes

Includes failures to identify, retain, store, preserve or protect biological samples needed for coronial, neonatal or other postmortem investigation, including hospital blood samples, tissue, stomach contents and placentae where their preservation is required for later pathological or toxicological analysis.

Not included

  • Excludes general clinical-record, document or non-biological evidence retention failures.
  • Excludes failures in conducting, interpreting or reporting a postmortem examination after the relevant biological samples have been reliably preserved.
  • Excludes ordinary laboratory sample storage or diagnostic testing where the sample is not needed for a postmortem, coronial or death investigation.
  • Excludes generic coronial governance or autopsy-quality deficiencies that do not concern retention or preservation of biological samples.
Reports
7

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2016–2025

First to latest report issue date

Stated actions
12

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 Care2
Recipient name withheld2
Royal Berkshire NHS Foundation Trust2
Royal College of Pathologists2
British Retail Consortium1
Cambridgeshire Constabulary1
Care Quality Commission1
East Kent Hospitals University NHS Foundation Trust1
Food and Drink Federation1
Food Standards Agency1
General Medical Council1
NHS England1
Nottingham University Hospitals NHS Trust1
Royal College of Obstetricians and Gynaecologists1
The British Society For Allergy & Clinical Immunology1

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. Cambridgeshire and Peterborough

    AI-generated summary

    Benedict BLYTHE · 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

    Benedict died at Peterborough City Hospital on 1 December 2021, aged 5, from fatal anaphylaxis following accidental exposure to cow’s milk protein. The report identifies concerns about the retention and testing of samples, including blood and stomach contents, and the police seizure and retention of relevant evidence such as vomitus during investigations of unexplained deaths.

    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 immediately store or freeze stomach contents for triggering-allergen analysis

    Wider context from the report

    “1) In relation to Pathology That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis: a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen c. blood samples if taken at hospital should not be destroyed but retained for testing d. that an early blood sample is taken after death and stored for later analysis e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity f. tissue samples are taken and retained. g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation. 2.) The police investigation: In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner. ”

    Source location

    Benedict BLYTHE · Prevention of Future Deaths report
    Page 3 · 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

    Failure to collect and store an early post-mortem blood sample for later analysis

    Wider context from the report

    “1) In relation to Pathology That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis: a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen c. blood samples if taken at hospital should not be destroyed but retained for testing d. that an early blood sample is taken after death and stored for later analysis e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity f. tissue samples are taken and retained. g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation. 2.) The police investigation: In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner. ”

    Source location

    Benedict BLYTHE · Prevention of Future Deaths report
    Page 3 · 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

    Failure to retain hospital blood samples for testing

    Wider context from the report

    “1) In relation to Pathology That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis: a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen c. blood samples if taken at hospital should not be destroyed but retained for testing d. that an early blood sample is taken after death and stored for later analysis e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity f. tissue samples are taken and retained. g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation. 2.) The police investigation: In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner. ”

    Source location

    Benedict BLYTHE · Prevention of Future Deaths report
    Page 3 · 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

    Failure to collect and retain tissue samples in suspected anaphylaxis

    Wider context from the report

    “1) In relation to Pathology That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis: a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen c. blood samples if taken at hospital should not be destroyed but retained for testing d. that an early blood sample is taken after death and stored for later analysis e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity f. tissue samples are taken and retained. g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation. 2.) The police investigation: In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner. ”

    Source location

    Benedict BLYTHE · 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

    Publish autopsy guidelines for suspected acute anaphylaxis, including blood and stomach-content sampling guidance.

    Verbatim wording from the response

    “The Kennedy Protocol has not been formally updated since 2016; it is not known when or if the protocol is to be revised. Since then Autopsy guidelines have been published on sudden unexpected death in infancy and childhood in 2023 under the remit of the Death Investigation Committee at the Royal College of Pathologists and these have superseded the 2016 publication. Neither the 2016 or 2023 guidelines included samples in cases of suspected anaphylaxis. However, the RCPath published autopsy guidelines on autopsies for suspected acute anaphylaxis (includes anaphylactic shock and anaphylactic asthma) in 2018. This document does include very specific guidance of sampling blood and stomach contents in such cases together with caveats for interpreting mast cell tryptase levels.”

    Source location

    Response from Royal College of Pathologists
    Page 1 · response
    Published 2 December 2025

    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

    Published anaphylaxis autopsy guidance and expected use of relevant guidance are considered sufficient despite paediatric guidelines lacking specific anaphylaxis details.

    Verbatim wording from the response

    “The Kennedy Protocol has not been formally updated since 2016; it is not known when or if the protocol is to be revised. Since then Autopsy guidelines have been published on sudden unexpected death in infancy and childhood in 2023 under the remit of the Death Investigation Committee at the Royal College of Pathologists and these have superseded the 2016 publication. Neither the 2016 or 2023 guidelines included samples in cases of suspected anaphylaxis. However, the RCPath published autopsy guidelines on autopsies for suspected acute anaphylaxis (includes anaphylactic shock and anaphylactic asthma) in 2018. This document does include very specific guidance of sampling blood and stomach contents in such cases together with caveats for interpreting mast cell tryptase levels.”

    Source location

    Response from Royal College of Pathologists
    Page 1 · response
    Published 2 December 2025

    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

    Femoral blood sampling in very young children may be impractical, requiring alternative sites that complicate interpretation of mast cell tryptase levels.

    Verbatim wording from the response

    “Early blood sampling is indicated but timing may be determined by the local post-mortem HTA 2004 arrangements in individual hospitals. In addition, it is extremely difficult to obtain femoral vessel blood samples in very young children purely due to the size of the individual and blood may”

    Source location

    Response from Royal College of Pathologists
    Page 1 · response
    Published 2 December 2025

    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

    Sample retention is determined by the requesting Coroner and subsequently by parental or next-of-kin consent under the Human Tissue Act 2004.

    Verbatim wording from the response

    “In all Coronial post-mortem examinations in children, tissue samples are taken primarily in accordance with the published protocols and also any that are relevant to ascertaining the cause of death. Retention of samples is determined initially by the Coroner requesting the post-mortem examination and thereafter by parental / next-of-kin consent in line with the Human Tissue Act 2004.”

    Source location

    Response from Royal College of Pathologists
    Page 2 · response
    Published 2 December 2025

    Open published response

  2. Berkshire

    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 train staff on placenta retention procedures

    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
    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

    Deliver and monitor staff training and communications on placenta storage, histology referral, retrieval, and disposal procedures.

    Verbatim wording from the response

    “From 1st February 2023 various communication strategies have been used to highlight the new processes with all midwifery and support staff. This focuses on highlighting the circumstances in which placentas must be sent for examination, the need for all placentas to be stored for 48 hours and processes for disposal. Posters are displayed on the communication boards and fridges and verbal communication has been undertaken at each handover. A series of training videos were made which show how to store the placentas following a home or hospital birth, how to send a placenta for histology and how to retrieve a placenta within 48 hours for sending for histology or safe disposal. The training videos also signpost the member of staff to the new SOP.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 2 · response
    Published 24 February 2023

    Open published response

  3. Avon

    AI-generated summary

    Celia Lindsey MARSH · 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

    Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.

    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 obtain and preserve stomach contents and tissue samples at post-mortem examination

    Wider context from the report

    “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA). I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling. Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically: • If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing • That an early blood sample is taken after death and stored for late analysis • That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity • That an early blood sample is taken after death • The post mortem examination should be prioritised. • At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation. In relation to doctors/patients: • To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group. • To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure. In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care: • To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content. • Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk. In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality: • The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim. • With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume. In relation to the FSA: • A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need. • Nationally recognised best practice and technical advice to assist those investigating such cases; ”

    Source location

    Celia Lindsey MARSH · Prevention of Future Deaths report
    Page 3 · 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

    Failure to obtain and store an early post-death blood sample for later analysis

    Wider context from the report

    “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA). I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling. Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically: • If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing • That an early blood sample is taken after death and stored for late analysis • That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity • That an early blood sample is taken after death • The post mortem examination should be prioritised. • At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation. In relation to doctors/patients: • To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group. • To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure. In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care: • To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content. • Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk. In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality: • The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim. • With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume. In relation to the FSA: • A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need. • Nationally recognised best practice and technical advice to assist those investigating such cases; ”

    Source location

    Celia Lindsey MARSH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Establishing the systems identified by the Coroner falls outside UKHSA’s remit.

    Verbatim wording from the response

    “Whilst we understand the seriousness of the failings leading to the death of Celia Marsh responsibility for establishing systems such as those referred to by the Coroner sit outside of the remit of UKHSA.”

    Source location

    Response UK Health Security Agency
    Page 1 · response
    Published 25 November 2022

    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

    Pathology policy responsibility lies with DHSC and the Royal College of Pathologists, rather than the respondent.

    Verbatim wording from the response

    “Your concerns regarding pathology have been noted, however this is not an area where the FSA has policy responsibility. I can see that your report has been directed to the Department for Health and Social Care (DHSC) and the Royal College of Pathologists who may be able to offer a response to these concerns. We are however, open to assisting other government departments where we can.”

    Source location

    Response from Food Standards Agency
    Page 3 · response
    Published 25 November 2022

    Open published response

  4. Berkshire

    AI-generated summary

    Adele Angel Massoudi · 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

    Adele Angel Massoudi was born at home on 26 June 2020, transferred to hospital, and died there on 2 July 2020; the recorded cause of death was severe hypoxic ischaemic encephalopathy. The report identified delays in responding to meconium, inadequate fetal heart-rate monitoring, delayed transfer to hospital, inadequate communication with the family, and destruction of the placenta without retaining it for examination. Concerns focused on midwifery training and the retention of placentas for death investigation.

    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 retain placentas when required for death investigation

    Wider context from the report

    “In terms of learning from these cases, examination of the placenta, either as part of a formal autopsy, or even without an autopsy, is absolutely vital. It is akin to asking a pathologist to conduct a post-mortem examination without one of the organs, if the placenta is not retained. I am concerned about the response from the hospital trust on this point. I am told that the guideline for placenta examination is being reviewed and I quote from the statement sent by the Director of Midwifery, dated 6 June 2022: We continue to explore opportunities that may extend placental storage. It does not go far enough simply to state “we are looking into it” at this stage, or that the trust does not have the space to store placentas for longer. I appreciate that the Human Tissue Act and other considerations have to be taken into account. It is not insurmountable, and I believe the trust must now be given a deadline for responding to this concern, in the format of a Regulation 28 Report, in order to ensure that a decision has been made. There are cases where keeping the placenta is clearly required - such as this case - because Adele was born in a poor condition. The practical realities have to be taken into account, and a line drawn as to when placentas should be kept for longer than usual. Currently, placentas in uncomplicated cases are being disposed of daily. ”

    Source location

    Adele Angel Massoudi · 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

    Store all placentas for 48 hours after birth using designated fridges and automated temperature monitoring.

    Verbatim wording from the response

    “Previously, placentas in uncomplicated cases were being disposed of on a daily basis but I can confirm that the Trust have implemented processes to ensure that all placentas are stored for 48 hours from the time of birth. We are advised by the Pathology team that retaining placentas beyond this time would not provide reliable histology findings.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 3 · response
    Published 20 September 2022

    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

    Ratify and implement the placenta-retention Standard Operating Procedure, including histology guidance and 48-hour storage requirements.

    Verbatim wording from the response

    “The Standard Operating Procedure (SOP) for placenta retention will be ratified at the Maternity Clinical Governance Meeting in October 2022 and will go live on 10 October 2022; it provides guidance on which placentas need to be sent to histology for pathological examination, as well as storing and retaining all placentas for 48 hours before disposal in uncomplicated cases. In order to disseminate this information, all of the Trust’s Band 7 midwives and Unit Coordinators will be trained on the new SOP to ensure compliance throughout maternity, and in particular the midwives and maternity support workers. We are also working with Waste Management to ensure that their team are fully aware of the new process, as they now need to request that a member of the midwifery team attends with them to ensure that the correct procedures are followed.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 3 · response
    Published 20 September 2022

    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

    Train Band 7 midwives and Unit Coordinators on the placenta-retention Standard Operating Procedure.

    Verbatim wording from the response

    “The Standard Operating Procedure (SOP) for placenta retention will be ratified at the Maternity Clinical Governance Meeting in October 2022 and will go live on 10 October 2022; it provides guidance on which placentas need to be sent to histology for pathological examination, as well as storing and retaining all placentas for 48 hours before disposal in uncomplicated cases. In order to disseminate this information, all of the Trust’s Band 7 midwives and Unit Coordinators will be trained on the new SOP to ensure compliance throughout maternity, and in particular the midwives and maternity support workers. We are also working with Waste Management to ensure that their team are fully aware of the new process, as they now need to request that a member of the midwifery team attends with them to ensure that the correct procedures are followed.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 3 · response
    Published 20 September 2022

    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

    Coordinate with Waste Management so midwifery staff attend placenta disposal and correct procedures are followed.

    Verbatim wording from the response

    “The Standard Operating Procedure (SOP) for placenta retention will be ratified at the Maternity Clinical Governance Meeting in October 2022 and will go live on 10 October 2022; it provides guidance on which placentas need to be sent to histology for pathological examination, as well as storing and retaining all placentas for 48 hours before disposal in uncomplicated cases. In order to disseminate this information, all of the Trust’s Band 7 midwives and Unit Coordinators will be trained on the new SOP to ensure compliance throughout maternity, and in particular the midwives and maternity support workers. We are also working with Waste Management to ensure that their team are fully aware of the new process, as they now need to request that a member of the midwifery team attends with them to ensure that the correct procedures are followed.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 3 · response
    Published 20 September 2022

    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 electronic safety-huddle templates to identify recent neonatal deterioration or admissions and prevent erroneous placenta disposal.

    Verbatim wording from the response

    “As an additional assurance, the safety huddle templates on our electronic patient record system will be updated to prompt the team to ask whether any babies have deteriorated or been admitted from other areas in the last 24 hours to the paediatric ward, who are less than 48 hours of age and require ventilation, cooling or neonatal death. This measure will be introduced to ensure that placentas are not erroneously disposed of due to any lack of communication between the maternity unit and paediatric ward.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 3 · response
    Published 20 September 2022

    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

    Retention of placentas beyond 48 hours would not provide reliable histology findings, so longer storage is not undertaken.

    Verbatim wording from the response

    “Previously, placentas in uncomplicated cases were being disposed of on a daily basis but I can confirm that the Trust have implemented processes to ensure that all placentas are stored for 48 hours from the time of birth. We are advised by the Pathology team that retaining placentas beyond this time would not provide reliable histology findings.”

    Source location

    Response from Royal Berkshire NHS Foundation Trust
    Page 3 · response
    Published 20 September 2022

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Quinn Lias Parker · 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

    Quinn Lias Parker was born in very poor condition and died two days later, after remaining extremely unwell from shortly after birth. The placenta was cut into or dissected after his death without discussion with the Coroner, limiting the paediatric post-mortem examination and the investigation into the circumstances and likely cause of death. The report also identifies repeated cases in which placental examination was compromised following early neonatal deaths in Nottingham.

    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 make careful, considered placenta-interference or disposal decisions with early coroner discussion

    Wider context from the report

    “1. The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case. 2. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner. This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning. 3. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction. ”

    Source location

    Quinn Lias Parker · 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

    Failure to retain the placenta for full paediatric post mortem examination before coronial reporting

    Wider context from the report

    “1. The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a paediatric post mortem- Loss of an organ at any post mortem examination, may well undermine the ability of the pathologist to carry out a full and proper examination. Decisions surrounding interference with, or disposal of, the placenta should be made in a careful and considered manner, with thought given to an early discussion with the coroner as would happen if organ donation is being considered. This did not happen in this case. 2. Unfortunately, there have been a number of cases in Nottingham where the death of a baby shortly after the birth was anticipated, but the placenta was disposed of and/or interfered with prior to the death being reported to the coroner. This undermines the coronial investigation resulting in limited findings and therefore limited conclusions at inquest. This will likely lead to a lack of learning from such deaths, and therefore a risk that similar deaths will occur in the future. It may also deprive the parents of significant information when considering whether future pregnancies may be at greater risk with the consequent need for appropriate management and planning. 3. The Nottinghamshire Coronial service has to date worked collaboratively with all local Trusts, but particularly with NUH NHS Trust, to ensure key staff understand the importance of retaining the placenta in an early neonatal death. This has not led to the actions necessary to achieve a full and proper examination of the placenta in repeated paediatric post mortems in this jurisdiction. ”

    Source location

    Quinn Lias Parker · 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

    Maintain a 96-hour stop on dissecting placentas sent to Pathology, allowing fixation during the period without dissection.

    Verbatim wording from the response

    “Last year, in the light of your PFD report, an immediate 48 hour stop was put on the dissection of all placentas. However we have since reviewed the proposed processes and the length of that stop has been extended and is now set at 96 hours (ie 4 days) for all placentas that are sent to Pathology. A placenta may be fixed during that period, to prevent its deterioration, but it will not be dissected.”

    Source location

    Response from NUH (3)
    Page 2 · response
    Published 6 October 2022

    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

    Discuss placenta examination with the Coroner’s office when a neonatal death occurs within the 96-hour Pathology stop period.

    Verbatim wording from the response

    “This along with the longer ‘stop’ period of 4 days will, we hope, ensure that for the majority of relevant deaths in the neo-natal period there will be an opportunity for your office to have further communication with Pathology regarding the examination of the placenta.”

    Source location

    Response from NUH (3)
    Page 2 · response
    Published 6 October 2022

    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 whether placental examination processes need adaptation after receiving further information about the examination.

    Verbatim wording from the response

    “In response to this Report the Trust will develop a standard procedure such that in the case of any neonatal death within 48 hours of birth the medical examiner team will inform the pathology laboratory of this at the very earliest opportunity. Once further information is gained in relation to the placental examination the Pathology Department will review whether there needs to be any adaptation to current examination processes.”

    Source location

    Response from NUH
    Page 2 · response
    Published 6 October 2022

    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

    The Trust considers a process to identify very unwell neonates for pre-death Coroner discussions impractical and unreliable because deaths are not predictable.

    Verbatim wording from the response

    “After consultation with Obstetricians, Neonatologists, Pathologists and Digital Lead, it is the view of the Trust that it is not proportionate nor practically achievable to devise a process that would reliably allow for this given that all of the 975 admissions to NICU each year are, by the very nature of NICU, neonates who are very unwell and may go on to die. The death of a neonate on NICU is not predictable in a way that could reliably allow us to identify the 25 or so neonates who do actually die each year. This is why we have determined that extending the Pathology stop period across the board for all placentas, and having discussions with your office where a death occurs within 96 hours, is a preferable and more realistically achievable approach.”

    Source location

    Response from NUH (3)
    Page 2 · response
    Published 6 October 2022

    Open published response

  6. North East Kent

    AI-generated summary

    HARRY RICHFORD · 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

    Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.

    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 retain placentae for examination after severe foetal distress

    Wider context from the report

    “Concern 12 The placenta of Harry was not retained. Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit. ”

    Source location

    HARRY RICHFORD · Prevention of Future Deaths report
    Page 16 · concerns

    Open source report

    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 Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.

    Verbatim wording from the response

    “I am advised that the Trust Board is taking these matters very seriously and has welcomed the national support being provided. I expect the Trust to set out in its response to your report the actions it is taking to address the important safety risks you have outlined.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 11 October 2022

    Open published response

  7. West Yorkshire Eastern

    AI-generated summary

    Angus Jonathan Labofski WEST · 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

    Angus Jonathan Labofski WEST was born on 24 January 2015 and became unwell shortly afterward, developing severe hypoxic-ischaemic encephalopathy. His death was confirmed at Martin House Children’s Hospice on 20 February 2015. The principal concern was that the placenta was not retained, limiting possible pathological examination into factors that might have contributed to his death.

    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 retain the placenta and all its appendages for pathological examination when a newborn is deteriorating and may die

    Wider context from the report

    “(1) After the baby was born the placenta was not retained. Within a short time after his birth he became unwell and despite all efforts his death was confirmed. It was likely that a post mortem examination would be needed to determine the cause of death. It would have been of assistance to the Pathologist to be able to examine the placenta to show the possibility of a toxoplasmosis infection; to establish if relevant the possibility of placental abruption and to establish if the umbilical cord was kinked, trapped or in any way damaged which could have caused or contributed to the death. I therefore recommend and request that when it is foreseeable that at birth or shortly thereafter, the baby’s condition is poor and is deteriorating which may lead to death, then the placenta and all its appendages should be retained and be made available to the Pathologist for further examination. ”

    Source location

    Angus Jonathan Labofski WEST · Prevention of Future Deaths report
    Page 1 · 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 24-hour retention of live-birth placentas through bagging, labelling, dating and refrigerated or labour-ward storage, followed by permitted disposal when conditions are satisfactory.

    Verbatim wording from the response

    “As a consequence of the tragic outcome in this case and the inquest findings we undertake to institute the following standard operating procedure in respect to retention of placenta following childbirth. Points a) and b) are current standard practice and the remaining points are to be instituted by September 1st 2016.”

    Source location

    2016-0158-Response-by-York-Teaching-Hospital
    Page 1 · response
    Published 20 April 2016

    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

    Retain placentas for poor-condition, extremely preterm or deteriorating babies locally for 30 days, then send them to Leeds for histopathology if the baby dies, subject to consent.

    Verbatim wording from the response

    “As a consequence of the tragic outcome in this case and the inquest findings we undertake to institute the following standard operating procedure in respect to retention of placenta following childbirth. Points a) and b) are current standard practice and the remaining points are to be instituted by September 1st 2016.”

    Source location

    2016-0158-Response-by-York-Teaching-Hospital
    Page 1 · response
    Published 20 April 2016

    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

    The Trust considers that its undertakings constitute all reasonable steps needed to prevent a similar occurrence.

    Verbatim wording from the response

    “I hope that this undertaking alleviates the concerns raised during the recent inquest and reassures you that all reasonable steps have been taken to prevent a similar occurrence in the future. I would be happy to write to you again after the proposed implementation date to confirm that the Trust has complied with these undertakings.”

    Source location

    2016-0158-Response-by-York-Teaching-Hospital
    Page 2 · response
    Published 20 April 2016

    Open published response
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Data last updated 7 September 2026