Recurring concern

Unreliable cord blood testing for newborn safety assessment

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First reported 19 May 2023•Latest report 16 Sep 2023

Definition

What this concern includes

Includes failures in the cord blood testing process, including requirements and standardisation, availability of haemoglobin or other clinically relevant measurements, correct sampling technique, equipment configuration, staff competence and assurance that results are accurate and usable for newborn assessment.

Not included

  • Excludes neonatal resuscitation, treatment or monitoring failures where cord blood testing is not the deficient control.
  • Excludes general laboratory, blood-gas analyser or clinical-information deficiencies that are not specifically tied to cord blood testing.
  • Excludes routine maternal or neonatal blood testing performed after birth when cord blood testing is not the material unsafe condition.
  • Excludes failures to act on accurate and available cord blood results when the testing process itself was reliable.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2023–2023

First to latest report issue date

Stated actions
1

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.

National Institute for Health and Care Excellence1
North West Anglia NHS Foundation Trust1
Royal College of Obstetricians and Gynaecologists1
Royal College of Paediatrics and Child Health1

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. Blackpool and the Fylde

    AI-generated summary

    Sienna Scarlett Monterio · 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

    Sienna Scarlett Monterio was born by emergency caesarean section on 6 April 2022 and died later that morning following a severe fetal-maternal haemorrhage. The report raises concern that blood gas analysers may not be configured to measure haemoglobin in neonatal resuscitation settings, with variation between trusts potentially limiting information available to clinicians; it states this issue did not contribute to Sienna’s death.

    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 make haemoglobin analysis available in neonatal resuscitation cord blood gas testing

    Wider context from the report

    “Having reviewed the circumstances surrounding Sienna’s death, the Healthcare Safety Investigation Branch [HSIB] found that at the time of birth the blood gas analyser was not set to analyse the haemoglobin. The HSIB very clearly state that in the absence of this data, this “prevented other possible causes for the Baby’s condition being considered and possibly corrected.” The HSIB has also recommended this facility is available in all neonatal resuscitation settings to support the provision of clinical information, and to optimise decision making processes and clinical care. Sienna was born following an urgent caesarean section, and died within two hours of delivery. Those who work in this area inevitably have to make urgent, life-saving decisions and in the most challenging of circumstances, and it seems to me that there is a lack of clarity on this issue which needs to be addressed. In the absence of such clarity, a baby may die from a preventable cause which is not appreciated by clinicians in the absence of data which would have highlighted a low haemoglobin level in the blood cord gas. It appears that in some trusts, this data will be readily available, but not in others. If ████████ comment above is correct, there may be different practices within the one trust. The court has been told that cord blood testing is not regulated or included in the Newborn Life Support (NLS) process at a national level. It appears as though the hospital trust in Blackpool is considering this issue appropriately, and this may reflect the picture nationally. The HSIB states this data may assist in identifying other possible causes for a baby’s condition being considered, and possibly corrected. ████████ expresses the view that he sees no potential disadvantage in having the Hb measurement being readily available in the cord blood gas from a clinical perspective. I have therefore concluded that there is risk of future deaths and that I therefore have a duty to write this report. ”

    Source location

    Sienna Scarlett Monterio · Prevention of Future Deaths report
    Page 3 · 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

    Lack of national regulation and Newborn Life Support process inclusion for cord blood testing

    Wider context from the report

    “Having reviewed the circumstances surrounding Sienna’s death, the Healthcare Safety Investigation Branch [HSIB] found that at the time of birth the blood gas analyser was not set to analyse the haemoglobin. The HSIB very clearly state that in the absence of this data, this “prevented other possible causes for the Baby’s condition being considered and possibly corrected.” The HSIB has also recommended this facility is available in all neonatal resuscitation settings to support the provision of clinical information, and to optimise decision making processes and clinical care. Sienna was born following an urgent caesarean section, and died within two hours of delivery. Those who work in this area inevitably have to make urgent, life-saving decisions and in the most challenging of circumstances, and it seems to me that there is a lack of clarity on this issue which needs to be addressed. In the absence of such clarity, a baby may die from a preventable cause which is not appreciated by clinicians in the absence of data which would have highlighted a low haemoglobin level in the blood cord gas. It appears that in some trusts, this data will be readily available, but not in others. If ████████ comment above is correct, there may be different practices within the one trust. The court has been told that cord blood testing is not regulated or included in the Newborn Life Support (NLS) process at a national level. It appears as though the hospital trust in Blackpool is considering this issue appropriately, and this may reflect the picture nationally. The HSIB states this data may assist in identifying other possible causes for a baby’s condition being considered, and possibly corrected. ████████ expresses the view that he sees no potential disadvantage in having the Hb measurement being readily available in the cord blood gas from a clinical perspective. I have therefore concluded that there is risk of future deaths and that I therefore have a duty to write this report. ”

    Source location

    Sienna Scarlett Monterio · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  2. Cambridgeshire and Peterborough

    AI-generated summary

    Amelia Barbosa · 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

    Amelia Barbosa suffered an acute hypoxic injury immediately before delivery that continued during resuscitation, and she died in hospital on 13 December 2020 at 7 days old. Concerns included unreliable cord blood sampling, delays in obtaining vascular access and administering treatment, inadequate consideration of blood transfusion before resuscitation stopped, and delayed effective cooling. The report also raised concerns that learning and training on these issues had not been fully implemented.

    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 ensure that all midwives apply correct cord blood sampling technique

    Wider context from the report

    “1. While I heard evidence that there has been training for Midwives on how to take cord blood, and I was provided with a copy of a poster that was said to have been in use at the Trust for some time, in April 2023, over 2 years after this delivery, the Midwife gave evidence that she and her colleagues were of the opinion that it was appropriate to take a sample from anywhere in the cord, not just in the clamped area. The expert and the Trust’s own Head of Midwifery advised that this was not appropriate. It therefore does not appear that the learning has been passed on to all Trust Midwives and there is a risk that in future cases those treating the baby will be falsely reassured by normal cord pH results which may not be accurate. ”

    Source location

    Amelia Barbosa · Prevention of Future Deaths report
    Page 3 · 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

    Issue guidance requiring cord blood sampling from the clamped cord area and escalation to paediatricians for capillary sampling if unsuccessful.

    Verbatim wording from the response

    “The first area of concern relates to the taking of cord blood samples by midwifery staff. You heard evidence at the inquest that the midwife in this case did indeed attempt to take a sample of blood from that part of the umbilical cord which had been clamped. Unfortunately, she was unable to obtain any blood from there and therefore obtained a sample from the unclamped part of the cord. Following the inquest the midwifery department has produced and issued a poster in relation to this. I have enclosed a copy of the poster which makes it clear that cord blood samples must be taken from the clamped area and not from any other part of the cord or placenta. If the midwife is unable to obtain any blood from this part of the cord then they are to inform the Paediatricians in order that they can take a capillary sample.”

    Source location

    Response from North West Anglia NHS Foundation Trust
    Page 1 · response
    Published 23 May 2023

    Open published response
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Data last updated 7 September 2026