First reported 14 Oct 2013•Latest report 5 Nov 2025
Definition
What this concern includes
Includes failures in pregnancy and birth risk assessment and planning where the report concerns individualised or holistic identification, communication, escalation, or management of risks to determine an appropriate birth plan, timing, or mode of delivery.
Not included
Excludes generic failures in training, documentation, staffing, communication, or continuity that are not specifically tied to pregnancy and birth risk assessment and planning.
Excludes consent or risk-discussion deficiencies that do not concern the assessment and planning of pregnancy or birth risks.
Excludes failures concerning unrelated clinical risk assessments, medication dosing, monitoring, or other safety processes.
Reports
11
Distinct published reports
Individual concerns
14
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
13
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 Care6
Royal College of Obstetricians and Gynaecologists3
National Institute for Health and Care Excellence2
Royal College of Midwives2
Chesterfield Royal Hospital NHS Foundation Trust1
Gateshead Health NHS Foundation Trust1
George Eliot Hospital NHS Trust1
Health Services Safety Investigations Body1
NHS England1
Nursing and Midwifery Council1
Portsmouth Hospitals University NHS Trust1
South Central Ambulance Service NHS Foundation Trust1
the Princess Alexandra Hospital NHS Trust1
University Hospitals Birmingham NHS Foundation Trust1
Worcestershire Acute Hospitals NHS Trust1
NHS trust7
Ministerial department6
Executive non-departmental public body3
Health professional body3
Trade union and professional body2
Health and care professional regulator1
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.
Manchester North
Concerns raised1
Failure to personalise and individualise pregnancy and birth risk assessment
This report raised 14 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Contribute to the task and finish group on national homebirth guidance, frameworks, ethical proportionality, informed risk discussions, maternal risks, terminology and training needs.
Stated by Nursing and Midwifery CouncilStated plannedThe respondent said that this action was planned when they made their response on 7 November 2025.
Action
Ask all NHS maternity providers to urgently review the safety and quality of their homebirth services.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 7 November 2025.
Action
Require trusts to implement risk assessment at each pregnancy contact, including ongoing review of intended place of birth.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 7 November 2025.
Action
Support obstetricians to provide women with information enabling informed choices about care during pregnancy, birth and the postnatal period.
Stated by Royal College of Obstetricians and GynaecologistsStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2025.
Action
Promote professional learning through member communications and resources on risk escalation, informed consent and safe decision-making for complex births.
Stated by Royal College of MidwivesStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2025.
Action
Advocate for clear national frameworks supporting consistent, individualised communication of maternal and neonatal risks across maternity settings.
Stated by Royal College of MidwivesStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Current NICE intrapartum guidance appropriately covers home births, and insufficient evidence justifies changing its recommendations.
Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Further research to quantify mortality risk for individuals at greater risk is needed from appropriate bodies.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Warwickshire
Concerns raised2
Failure to ensure appropriate timing and mode of delivery in high-risk pregnancies
Failure to ensure holistic review of relevant findings when planning timing and mode of birth
This report raised 8 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.
Birmingham and Solihull
Concerns raised1
Failure to involve patients’ named obstetric consultants in multiprofessional appointments
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Hold biweekly multidisciplinary meetings for joint discussion and planning with the named consultant.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Audit multidisciplinary input for high-risk home births to evidence consultant involvement in birth plans.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Allocate a consultant to regular multidisciplinary meetings following completion of consultant job planning.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Action
Review and align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
Derby and Derbyshire
Concerns raised1
Failure to assess and document the potential impact of KTS on pregnancy
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Worcestershire
Concerns raised1
Failure to give due weight to infection risk from retained foetus in delivery discussions following feticide
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.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 progressThe respondent said that this action was in progress when they made their response on 4 November 2021.
Gateshead and South Tyneside
Concerns raised3
Failure to prepare a risk-based birth plan with appropriate environment and skilled staff for macrosomic babies
Failure to plan and counsel on timing and mode of delivery for suspected larger babies
Failure to assess maternal and fetal risk before selecting a Birthing Pool delivery
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.
Manchester South
Concerns raised1
Lack of routine pre-delivery scanning for breech presentation
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Routine third-trimester scans are not recommended because no evidence supports them; lack of equipment or training is not the reason they are absent.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Portsmouth and South East Hampshire
Concerns raised1
Failure of antenatal growth-risk assessment to include maternal BMI and emerging risk factors
This report raised 11 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.
North London
Concerns raised1
Failure to rebut a cost-based presumption in favour of vaginal delivery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Department cannot comment on why caesarean delivery was not attempted earlier or whether cost influenced that decision.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The hospital trust must consider why caesarean delivery was not attempted earlier and whether cost influenced that decision.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Bedfordshire and Luton
Concerns raised1
Failure to coordinate an agreed delivery plan between tertiary and local hospitals
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Amend the obstetric ultrasound policy to require consultants to obtain and clearly document agreed delivery and neonatal care plans.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 February 2016.
Action
Disseminate the amended policy by adding it to the Trust guidelines folder and notifying obstetric doctors.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 February 2016.
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Includes failures in pregnancy and birth risk assessment and planning where the report concerns individualised or holistic identification, communication, escalation, or management of risks to determine an appropriate birth plan, timing, or mode of delivery.
