First reported 1 Jun 2016•Latest report 13 Dec 2024
Definition
What this concern includes
Includes failures in maternity or emergency-care processes to recognise when obstetric input is needed and promptly request, call or obtain obstetric review, including delayed recognition of pregnancy, failure to trigger obstetric review after specified clinical events, and comparable delays in escalating maternity concerns.
Not included
Excludes general maternity communication, coordination or staffing deficiencies where the failure is not specifically recognition of a need for obstetric input and prompt escalation.
Excludes pregnancy and birth risk-assessment or birth-planning failures where obstetric escalation is not the deficient control.
Excludes failures in obstetric treatment or review after the obstetric team has been promptly contacted.
Excludes non-maternity specialist escalation processes and generic emergency escalation without a material obstetric context.
Reports
4
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2016–2024
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.
Royal College of Obstetricians and Gynaecologists2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Care Quality Commission1
General Medical Council1
London Ambulance Service NHS Trust1
Mid and South Essex NHS Foundation Trust1
St Peter's Hospital1
the Shrewsbury and Telford Hospital NHS Trust1
Whittington Health NHS Trust1
NHS trust4
Health professional body2
Health and care professional regulator1
Health and social care service regulator1
Healthcare site1
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.
Essex
Concerns raised1
Delays in escalating deteriorating maternity patients for senior and critical care review
This report raised 15 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.8
Action
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Provide guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.
Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Teach and practise SBAR escalation during annual multidisciplinary PROMPT training.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Launch the RCOG escalation toolkit, including AID language, conflict-resolution teaching and team-of-shift handover practices.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
Action
Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024.
Action
Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Adopt a rota requiring junior registrars to pair with senior registrars and establish supervision and risk-mitigation arrangements when the intended skill mix is unavailable.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Inner North London
Concerns raised2
Failure to involve the obstetric team in the assessment and management of pregnant emergencies
Delays in recognising pregnancy and calling the obstetric team
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Launch criteria for initiating an obstetric call before a patient's arrival, jointly agreed by obstetric and emergency teams.
Stated by Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Action
Replace the Emergency Department priority-call information sheet with a version prompting staff to ask whether a relevant patient is pregnant.
Stated by Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The emergency department’s treatment decisions are the Whittington Hospital’s responsibility, although LAS measures may support more timely future care.
Stated by London Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Shropshire, Telford and Wrekin
Concerns raised2
Failure to request obstetric review after 1 hour of active pushing
Failure to request obstetric review for maternal tachycardia
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.
Surrey
Concerns raised1
Failure to provide timely obstetric consultant supervision after emergency admission
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.
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
Implement daily consultant review of patients on Joan Booker Ward, with labour ward consultant cover when usual consultants are unavailable.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 June 2016.
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Includes failures in maternity or emergency-care processes to recognise when obstetric input is needed and promptly request, call or obtain obstetric review, including delayed recognition of pregnancy, failure to trigger obstetric review after specified clinical events, and comparable delays in escalating maternity concerns.
