Recurring concern

Unsafe clinical learning environments for trainee midwives

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First reported 30 Jul 2015•Latest report 31 Dec 2021

Definition

What this concern includes

Includes failures of the maternity clinical-learning environment for student or trainee midwives, including unsuitable clinical exposure, supervision or support, unclear escalation routes, inadequate learning-environment governance, and failure to implement dedicated safe-learning standards where these affect trainee practice and patient safety.

Not included

Excludes general workplace culture, bullying or harassment concerns that are not materially connected to the safety of the clinical learning environment or trainee midwives.
Excludes generic maternity staffing, clinical-care, fetal-monitoring or CTG-interpretation failures where no clinical-learning-environment deficiency is identified.
Excludes general education or training-quality concerns outside clinical practice and the maternity trainee-learning environment.
Excludes failures confined to the competence or conduct of a permanent clinician where no trainee-learning or clinical-environment control is deficient.

Reports: 2
Individual concerns: 2
Date range: 2015–2021
Stated actions: 1

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

NHS England1

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.

31 Dec2021
Greater Manchester South
Concerns raised1
1. Lack of clear escalation processes for trainee midwives
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Jos Tarse-Joy · 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

Jos Tarse-Joy was born by emergency caesarean section at 41 weeks after his high-risk pregnancy was not explicitly identified to his parents or care team, no induction had been arranged, and CTG monitoring was not used on admission. He was born in very poor condition, sustained severe brain damage following hypoxia, and died at Royal Oldham Hospital on 15 December 2020. The principal concerns included communication and documentation failures, lack of appropriate monitoring and induction planning, unclear escalation processes, and wider issues concerning maternity-service layout and national guidance.

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 clear escalation processes for trainee midwives
Wider context from the report
“5. A student midwife was involved in the care. She followed the plan developed with an experienced midwife carefully. There was a lack of clarity regarding the escalation process she needed to follow if she identified problems. The evidence was that to avoid delay it was important that Trusts had clear escalation policies in place to appropriately support trainee midwives. ”
Source location
Jos Tarse-Joy · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Jul2015
Bedfordshire and Luton
Concerns raised1
1. Unsuitability of the clinical learning environment for Student Midwives
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Monitor post-placement student evaluations, share feedback and support joint remedial action where necessary.
  Stated by Health Education East of EnglandStated planned
Respondent positions 2
1. Position
  The incident did not reflect wider problems with supervision or education of midwifery students at Bedford Hospital.
  Stated by Health Education East of EnglandDisputes the concern
1. Position
  Existing supervision, placement auditing, academic support and quality-assurance arrangements support continued use of Bedford Hospital as a clinical learning environment.
  Stated by Health Education East of EnglandExisting arrangements considered sufficient
AI-generated summary

Casey Paul GARRETT · 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

Casey Paul Garrett was born at Bedford Hospital on 10 September 2014 and died on 11 September 2014 at 07:10 from perinatal asphyxia. The inquest identified failures to recognise his deteriorating condition and escalate care to expedite delivery, while the stated concerns included insufficient fetal monitoring, misinterpretation of a CTG trace, failure to escalate care, and the suitability of the hospital as a clinical learning environment for student midwives.

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
Unsuitability of the clinical learning environment for Student Midwives
Wider context from the report
“My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring, mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm”. 1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future. ”
Source location
Casey Paul GARRETT · 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
Monitor post-placement student evaluations, share feedback and support joint remedial action where necessary.

Verbatim wording from the response
“Every student completes a post placement evaluation. University of Bedfordshire and HEEoE will monitor these carefully and implement any necessary remedial actions. This will be achieved through increased link-lecturer involvement within the placement area, sharing of student feedback and joint action with Bedford Hospital NHS Trust.”

Source location
2015-0305-Response-by-Health-Education-East-of-England
Page 4 · response
Published 30 July 2015
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 incident did not reflect wider problems with supervision or education of midwifery students at Bedford Hospital.

Verbatim wording from the response
“Following the incident, a full internal investigation was completed by Bedford Hospital NHS Trust and the University of Bedfordshire into the suitability of the learning environment. It was established that the events that had led to the tragic death of Baby Casey Paul Garrett did not reflect any wider issues with the supervision and education of midwifery students at Bedford Hospital. Analysis of current supervision and capacity indicates in excess of a 2:1 ratio of mentors to students, all of whom have undertaken a recent mentorship programme.”

Source location
2015-0305-Response-by-Health-Education-East-of-England
Page 2 · response
Published 30 July 2015
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
Existing supervision, placement auditing, academic support and quality-assurance arrangements support continued use of Bedford Hospital as a clinical learning environment.

Verbatim wording from the response
“Following the incident, a full internal investigation was completed by Bedford Hospital NHS Trust and the University of Bedfordshire into the suitability of the learning environment. It was established that the events that had led to the tragic death of Baby Casey Paul Garrett did not reflect any wider issues with the supervision and education of midwifery students at Bedford Hospital. Analysis of current supervision and capacity indicates in excess of a 2:1 ratio of mentors to students, all of whom have undertaken a recent mentorship programme.”

Source location
2015-0305-Response-by-Health-Education-East-of-England
Page 2 · response
Published 30 July 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of clear escalation processes for trainee midwives

Concerns raised1

Unsuitability of the clinical learning environment for Student Midwives

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Actions described in response 1

Respondent positions 2