Recurring concern

Failure to ensure pregnant women have an individualised birth plan

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First reported 20 Oct 2021•Latest report 30 Jun 2023

Definition

What this concern includes

Includes failures in the maternity birth-planning process, including failure to discuss birthing options, engage the woman in decisions, develop or record an individualised birth plan, and communicate the agreed preferences to those providing care.

Not included

  • Excludes pregnancy or birth risk-assessment and planning failures where the concern is assessment of clinical risk, timing or mode of delivery rather than the woman’s informed birth preferences.
  • Excludes failures in fetal monitoring, clinical treatment or emergency escalation during labour that do not concern the birth-planning process.
  • Excludes generic care-planning deficiencies outside maternity birth planning.
  • Excludes consent or communication failures unrelated to discussing and recording preferences for labour and birth.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2021–2023

First to latest report issue date

Stated actions
11

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.

Milton Keynes University Hospital1
Royal College of Obstetricians and Gynaecologists1
Sheffield Teaching Hospitals NHS Foundation Trust1
University Hospitals Birmingham NHS Foundation Trust1
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.

  1. Birmingham and Solihull

    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 provide patients with a fully informed multiprofessional birth-choice discussion

    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
    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 two consultant midwives to share birth-choice discussions and planning for women requesting homebirth outside guidance.

    Verbatim wording from the response

    “• There are now two consultant midwives in post who share the birth choices discussion and planning for women requesting homebirth outside of guidance.”

    Source location

    Response from University Hospitals Birmingham NHS Foundation Trust
    Page 2 · response
    Published 7 July 2023

    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

    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
    Page 2 · response
    Published 7 July 2023

    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

    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
    Page 2 · response
    Published 7 July 2023

    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 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
    Page 2 · response
    Published 7 July 2023

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Millie-Rae Needham · 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

    Millie-Rae Needham was born on 6 August 2020 and died in the neonatal unit on 9 August 2020 after a 23-minute delay in delivery during which her condition was not adequately monitored. Concerns included the move from consultant-led to midwife-led care without consultation, inadequate foetal heart-rate monitoring, limited discussion of birthing options, and safeguards for patients not receiving continuous monitoring.

    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 discussion of birthing options before labour

    Wider context from the report

    “3. The lack of discussion with ████████ about birthing options prior to labour and therefore the lack of engagement with the pregnant woman is concerning. ”

    Source location

    Millie-Rae Needham · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Worcestershire

    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 provide informed consent discussions and facilitate maternal wishes regarding mode of delivery

    Wider context from the report

    “1) Informed consent and material choice regarding mode of delivery – I am concerned that enough emphasis is not being given to maternal wishes regarding mode of delivery. This issue appears to be a recurring theme in obstetric practice, and I am concerned that the culture in this area appears to still not fully accepting of the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section) and of facilitating the wishes of pregnant women and holding full and frank discussions about the risks and benefits and the pros and cons of the different options. I am concerned that situations might arise, like it appeared happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health. Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussions held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk/benefits of differing management plans. ”

    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

    Adopt the IDECIDE tool in the maternity information system to support and document informed mode-of-delivery decisions.

    Verbatim wording from the response

    “The IDECIDE tool has already been built into the BadgerNet maternity information system, however NHSX has asked that CleverMed to hold off on making this available to sites in the live BadgerNet mode. NHSX want to ensure other vendors have the opportunity to create a version, and are working on taking the design CleverMed have created into a more generic specification. CleverMed have asked NHSX for a timescale of when they could start a pilot or involve BadgerNet sites however this has yet to be agreed.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 2 · 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

    Introduce personalised care plans in the BadgerNotes app for discussion, review and professional authorisation.

    Verbatim wording from the response

    “C) Personalised care plans are being introduced at WHAT in January 2022, this will give women the ability to complete a birth plan within their BadgerNotes app, the plan must be discussed, reviewed and authorised by a Healthcare professional.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · 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

    Provide monthly multidisciplinary maternity training covering human factors, informed consent, Montgomery, balanced counselling and documentation.

    Verbatim wording from the response

    “D) Training at WAHT in maternity is multi professional and this takes place on a monthly basis. Included within this a section is dedicated to human factors, Informed consent and reference is made to the Montgomery ruling and balanced counselling and documentation. This case highlighted the importance of contemporaneous documentation regarding mode of delivery discussions and decisions.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · 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

    Establish and audit a robust process for managing requests for Caesarean Section during labour.

    Verbatim wording from the response

    “E) Following the Ockenden Review, one of the immediate essential actions is for review of management of maternal request for Caesarean Section for both elective cases and during labour. This is a challenge for all maternity units across the country and is a matter being considered carefully by the Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM). The trust performance and progress with this action will be monitored via the Local Maternity & Neonatal System (LMNS) as part of the National Perinatal Quality Surveillance tool. In the first review by NHSEI the trust have received an amber rating for this as we do not currently have a robust audit process for “in labour” requests for Caesarean Section. Our initial action to improve this position would be to develop an achievable process and to appoint an ‘Audit & Guideline Midwife’.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · 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

    Appoint an Audit and Guidelines Midwife to support Caesarean-request process development and audit.

    Verbatim wording from the response

    “E) Following the Ockenden Review, one of the immediate essential actions is for review of management of maternal request for Caesarean Section for both elective cases and during labour. This is a challenge for all maternity units across the country and is a matter being considered carefully by the Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM). The trust performance and progress with this action will be monitored via the Local Maternity & Neonatal System (LMNS) as part of the National Perinatal Quality Surveillance tool. In the first review by NHSEI the trust have received an amber rating for this as we do not currently have a robust audit process for “in labour” requests for Caesarean Section. Our initial action to improve this position would be to develop an achievable process and to appoint an ‘Audit & Guideline Midwife’.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · response
    Published 4 November 2021

    Open published response

  4. Milton Keynes

    AI-generated summary

    Poppy HARRIS · 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

    Poppy Harris was born on 23 November 2020 after a protracted labour and delivery using Kielland’s forceps. She was transferred to John Radcliffe Hospital, where a spinal cord injury was discovered, and she died on 24 March 2021. The substantive concerns were the absence of a birth plan or documented treatment preferences and the use of Kielland’s forceps, which the report states caused a catastrophic spinal cord injury.

    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 complete a birth plan recording the mother’s treatment and care preferences during labour

    Wider context from the report

    “1. I am concerned that when ████████, Poppy’s Mum, came into the hospital she did not have a birth plan and the midwives did not attempt to complete one. There was therefore no indication as to her preferences for treatment and care throughout her labour. ”

    Source location

    Poppy HARRIS · Prevention of Future Deaths report
    Page 1 · concerns

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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 how women’s birth preferences are discussed and documented.

    Verbatim wording from the response

    “Following on from Poppy’s inquest – and recognising the need to take stock following on from iterative changes to maternity pathways over the course of the COVID-19 pandemic – we have undertaken a review of how we ensure that women's birth preferences are discussed and documented.”

    Source location

    Response-from-Milton-Keynes-University-Hospital
    Page 2 · response
    Published 21 October 2021

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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 34-week antenatal appointments to one hour for structured discussion and standardised electronic and printed documentation of birth preferences.

    Verbatim wording from the response

    “At 34 weeks, the length of the appointment will be extended from 20 minutes to one hour. In this time, the midwife will complete the routine antenatal checks and discuss the woman's questions, wishes and birth preferences, recording this on a standardised form. The design of the form will have input from the local Maternity Voices Partnership. We will keep abreast of regional and national initiatives and consider reverting to a standardised process as and when established.”

    Source location

    Response-from-Milton-Keynes-University-Hospital
    Page 3 · response
    Published 21 October 2021

    Open published response
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Data last updated 7 September 2026