Recurring concern

Unreliable classification and management of meconium during childbirth

First to latest report 9 Oct 2018 — 17 Dec 2021

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 4

What this concern includes

Includes failures in the dedicated maternity process for recognising, classifying, documenting and managing meconium, including inconsistent terminology or significance thresholds and failure to initiate required equipment or other safety controls when meconium is present.

What is not included

Excludes generic maternity communication, documentation, training or equipment deficiencies unless they directly concern classification or management of meconium.
Excludes other intrapartum hazards, fetal monitoring and neonatal-care failures where meconium is not the identified concern.
Excludes failures occurring after meconium has been reliably classified and managed unless they are part of the same meconium-specific process.

Trends

Reports over time

Reports mentioning this concern, 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

Homerton Healthcare NHS Foundation Trust1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

17 Dec2021
Inner North London
Concerns raised1
1. Lack of standardised terminology for describing meconium
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Homerton Healthcare NHS Foundation Trust
Stated actions 4
1. Homerton Healthcare NHS Foundation Trust
  Implement the approved meconium grading-system upgrade, including clinician prompts to record rationale and required escalation.
2. Homerton Healthcare NHS Foundation Trust
  Update and circulate maternity policies to replace Grade I–III meconium terminology with significant/insignificant terminology.
3. Homerton Healthcare NHS Foundation Trust
  Deliver specific staff training on identifying significant or insignificant meconium and using the new terminology in communication and records.
1. Homerton Healthcare NHS Foundation Trust
  Use daily safety huddles and handovers to remind staff about the revised meconium terminology and related changes.
AI-generated summary

Ziggy Dylan MITCHELL-STAGG · 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

Ziggy was born by emergency Caesarean section at Homerton University Hospital on 3 April 2021 in a very compromised state and died a few hours later. The concerns included inconsistent terminology for meconium, a lack of a medical-record entry by the attending obstetric registrar after 3.46am, no local policy on centralised CTG monitoring, and a trust policy providing for fresh-eyes reviews every two hours rather than the hourly 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 standardised terminology for describing meconium
Wider context from the report
“1. There was not standardisation of the terminology used by the midwives and obstetricians to describe the meconium found, and the information requested by the computer system to record this did not necessarily reflect the verbal descriptions. Sometimes grades I, II & III were used; sometimes significant & insignificant; sometimes thick or thin. There was also inconsistency as to whether grade II was significant, and whether the term significant referred purely to the meconium noted, or to the meconium in the context of other features. ”
Source location
Ziggy Dylan MITCHELL-STAGG · 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
Implement the approved meconium grading-system upgrade, including clinician prompts to record rationale and required escalation.

Verbatim wording from the response
“a) Our computer system upgrade was already in place before the inquest, and one of the upgrades included updating the meconium grading from Grade I, II & III to the new system of Significant and Insignificant. The Trust has approved this change. A text box will now flash up once significant/insignificant is selected that will allow the clinician to enter the reason why they made that selection and when any onward action/escalation is needed. This change has been finalised and will be implemented by March 2022.”

Source location
2021-0425-Homerton-University-Hospital_Published
Page 1 · response
Published 22 December 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
Update and circulate maternity policies to replace Grade I–III meconium terminology with significant/insignificant terminology.

Verbatim wording from the response
“b) As stated above, the Trust acknowledges that the grading of meconium is not up to date and is inconsistent. We therefore plan to hold a ‘Meconium Awareness Month’ where the following will happen:-”

Source location
2021-0425-Homerton-University-Hospital_Published
Page 1 · response
Published 22 December 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
Deliver specific staff training on identifying significant or insignificant meconium and using the new terminology in communication and records.

Verbatim wording from the response
“b) As stated above, the Trust acknowledges that the grading of meconium is not up to date and is inconsistent. We therefore plan to hold a ‘Meconium Awareness Month’ where the following will happen:-”

Source location
2021-0425-Homerton-University-Hospital_Published
Page 1 · response
Published 22 December 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
Use daily safety huddles and handovers to remind staff about the revised meconium terminology and related changes.

Verbatim wording from the response
“• daily safety huddles and handovers will ensure that staff are reminded of this change and will be encouraged to take time to review all the changes;”

Source location
2021-0425-Homerton-University-Hospital_Published
Page 2 · response
Published 22 December 2021
Open published response
9 Oct2018
North London
Concerns raised2
1. Failure to use CCG equipment when meconium is present
2. Failure to classify meconium as meconium rather than grading its presence
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Alba May Pemberton · 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

Alba May Pemberton was born on 10 August 2016 after experiencing hypoxia during the active second stage of delivery and lived for two days. The report identified delayed five-minute heart monitoring and the possible absence of earlier CTG monitoring as concerns, noting that earlier detection and delivery might have resulted in survival. Concerns also included the classification of meconium, use of CTG equipment, obstetric review at birthing centres, and closer multidisciplinary working.

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 use CCG equipment when meconium is present
Wider context from the report
“The presence of meconium should be classified as meconium, and not graded, and once present should result in the use of CCG equipment. ”
Source location
Alba May Pemberton · Prevention of Future Deaths report
Page 1 · 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 classify meconium as meconium rather than grading its presence
Wider context from the report
“The presence of meconium should be classified as meconium, and not graded, and once present should result in the use of CCG equipment. ”
Source location
Alba May Pemberton · Prevention of Future Deaths report
Page 1 · concerns
Open source report