Recurring concern

Unreliable emergency management of breech birth

First to latest report 1 Mar 2018 — 16 Sep 2025

Reports that mention this concern
3
Times this concern has been raised
5
Stated actions linked to this concern
11

What this concern includes

Includes failures in the dedicated emergency management of breech birth, including recognition of breech presentation or delayed delivery, application and adequacy of JRCALC or equivalent guidance, decision-making about intervention or transfer to obstetric care, paramedic competence and access to continuing expert support.

What is not included
  • Excludes general maternity staffing, training or obstetric escalation deficiencies where breech birth is not the material safety condition.
  • Excludes routine antenatal birth planning, mode-of-delivery counselling and non-emergency maternity care unless the assertion specifically concerns emergency management of breech birth.
  • Excludes failures in neonatal care after delivery where the breech-birth emergency-management process operated adequately.
  • Excludes generic ambulance response, referral or clinical-guidance deficiencies without a supported breech-birth context.

Reports and published responses 3 reports

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

  1. Birmingham and Solihull

    AI-generated summary

    Mohammed Ismail KHAN · 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

    Mohammed Ismail Khan sustained a catastrophic brain injury during a breech delivery at 35 weeks and 2 days gestation on 6 September 2022, after his mother had been discharged from hospital earlier that day despite antenatal risk factors. He later died following a respiratory infection, with the medical cause of death recorded as respiratory failure due to parainfluenza virus infection, with hypoxic-ischaemic brain damage. The investigation identified delayed and suboptimal emergency care, failure to adhere to breech-delivery guidance, and the absence of mandatory paramedic training in obstetric emergencies as substantive concerns.

    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 mandatory and comprehensive paramedic training in obstetric emergencies

    Wider context from the report

    “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted. 3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development. 4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised. 5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses. 6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course. 7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk. ”

    Source location

    Mohammed Ismail KHAN · Prevention of Future Deaths report
    Page 2 · 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 adhere to clinical guidance for assessing and managing delayed breech birth

    Wider context from the report

    “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted. 3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development. 4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised. 5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses. 6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course. 7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk. ”

    Source location

    Mohammed Ismail KHAN · 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

    Provide regulated obstetric-emergency and breech-birth training through the AAP and Graduate Paramedic Induction programmes.

    Verbatim wording from the response

    “Training for obstetric emergencies is provided within The Level 4, 5 and 6 Associate Ambulance Practitioner (AAP) Programme which is a regulated training programme for all student paramedics on the apprenticeship pathway employed by WMAS.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 3 · response
    Published 19 September 2025

    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 practical breech-birth simulation sessions using Victoria mannequins and other maternity training equipment, updated following the new guidance.

    Verbatim wording from the response

    “The Trust invested in 5 “Victoria” mannequins at a cost of £69,000 each at the end of 2023 making simulation more realistic. These state of the art simulators are unique in their ability to autonomously simulate childbirth and integrate seamlessly with the Trust’s Zoll Series monitor enabling real-time monitoring of the mother’s vital signs during training scenarios. Victoria offers ambulance staff the most realistic and immersive training experiences for handling all obstetric emergencies including breech birth.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 3 · response
    Published 19 September 2025

    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

    Purchase and deploy five Victoria birthing mannequins for realistic obstetric-emergency simulation training.

    Verbatim wording from the response

    “The Trust invested in 5 “Victoria” mannequins at a cost of £69,000 each at the end of 2023 making simulation more realistic. These state of the art simulators are unique in their ability to autonomously simulate childbirth and integrate seamlessly with the Trust’s Zoll Series monitor enabling real-time monitoring of the mother’s vital signs during training scenarios. Victoria offers ambulance staff the most realistic and immersive training experiences for handling all obstetric emergencies including breech birth.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 3 · response
    Published 19 September 2025

    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

    Include obstetric emergencies, including breech birth, in mandatory face-to-face refresher training for all ambulance clinicians during 2026–2027.

    Verbatim wording from the response

    “West Midlands Ambulance Service clinicians partake in yearly refresher mandatory training both face to face in a classroom and online. Prior to this PFD being issued discussions and planning had taken place to include obstetric emergencies including breech birth within next year’s 2026/27 face to face mandatory training.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 4 · response
    Published 19 September 2025

    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 continuing professional development through maternity roadshows, themed maternity learning and expert-led obstetric-emergency simulation.

    Verbatim wording from the response

    “The Trust has put multiple measures in place to provide Continual Professional Development (CPD) to our staff including well attended “Maternity Roadshows” led by ████████ in September and October 2023 where a Victoria mannequin was utilised to simulate births and obstetric emergencies supported by the Maternity Champions. In September 2023, we held a themed Maternity Month where Maternity Roadshows were held with 9 expert guest speakers. On October 9th 2024, one of the guest speakers was a Breech Specialist Midwife from Birmingham Women’s Hospital who demonstrated a live breech birth simulation using a Victoria mannequin.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 4 · response
    Published 19 September 2025

    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

    Relaunch the e-PROMPT obstetric-emergency course and make it available for clinicians to complete.

    Verbatim wording from the response

    “Response At the time of the Inquest, the e-PROMPT course was paused due to updates and changes in national guidance so our clinicians could not complete this additional training. This was not due to resourcing. The course has now been relaunched and on 16th October 2025 our Education and Training Department advertised this in our Weekly Briefing and clinicians can now complete this.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 5 · response
    Published 19 September 2025

    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 the paramedic breech birth algorithm with manoeuvre guidance, illustrations, videos and step-by-step advice.

    Verbatim wording from the response

    “It is noted that Mohammed was born using the Lovesset’s manoeuvre. At the time of the incident, the paramedic breech birth algorithm did not provide sufficient detail on how to perform the full manoeuvre. The guidance has since been updated to make it clear and allow paramedics to use this manoeuvre safely and effectively when needed.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 2 · response
    Published 19 September 2025

    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

    Require ambulance clinicians to review the updated JRCALC breech-delivery guidance during Clinical Supervision shifts.

    Verbatim wording from the response

    “A Clinical Supervision shift (CS1) is mandatory for all ambulance clinicians and during this shift planned in the year 2024/25, staff were informed to review the new JRCALC guidance on breech delivery.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 3 · response
    Published 19 September 2025

    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 enhance the JRCALC breech-birth guideline using evidence review, expert consensus, paramedic usability testing, images and instructional videos.

    Verbatim wording from the response

    “The JRCALC guidelines contain guidance on the assessment and management of maternal emergencies, and we have a specific guideline for breech birth. The guideline was updated in September 2023 following extensive review by obstetricians, midwives, and paramedics. During the ████████”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 1 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The e-PROMPT course was unavailable because guidance updates paused it, not because resourcing prevented clinicians from completing it.

    Verbatim wording from the response

    “Response At the time of the Inquest, the e-PROMPT course was paused due to updates and changes in national guidance so our clinicians could not complete this additional training. This was not due to resourcing. The course has now been relaunched and on 16th October 2025 our Education and Training Department advertised this in our Weekly Briefing and clinicians can now complete this.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 5 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Relevant obstetric content in broader refresher training and CPD, alongside accessible JRCALC guidance, is considered sufficient without a standalone mandatory module.

    Verbatim wording from the response

    “Operational staff have access to the JRCALC clinical guidelines, which provide evidence-based guidance for the management of obstetric emergencies. These guidelines are readily available and regularly updated.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 6 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for paramedic training and education falls outside AACE’s remit.

    Verbatim wording from the response

    “With regard to your matter of concern around the training and education of paramedics, AACE are not responsible for this. However, we have shared the report via our networks and specifically with the national education network for ambulance trusts (NENAS), with the national pre-hospital maternity and newborn care group and the national ambulance services medical directors’ group (NASMeD) for them to consider your matters of concern in their own organisations.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 2 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Training concerns were shared with ambulance education and clinical networks for consideration by their organisations.

    Verbatim wording from the response

    “With regard to your matter of concern around the training and education of paramedics, AACE are not responsible for this. However, we have shared the report via our networks and specifically with the national education network for ambulance trusts (NENAS), with the national pre-hospital maternity and newborn care group and the national ambulance services medical directors’ group (NASMeD) for them to consider your matters of concern in their own organisations.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 2 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Qualified paramedic maternity training is the responsibility of individual ambulance trusts.

    Verbatim wording from the response

    “With regard to under-graduate and post-graduate paramedic training we are aware of variation in the provision of training for paramedics in maternity care and breech birth in both Universities (accredited by the HCPC) and ambulance services which for qualified paramedics is the responsibility of individual ambulance trusts. Additionally, we do not have any control over the allocation of specific funding for maternity training. We are aware that some training is delivered face-to-face to staff, often supplemented by online modules, webinars, and instructional videos. Simulation and hands on practice are widely used with training covers both theoretical and practical skills. Refresher training varies with some services offering training every 1-4 years, annually or as a part of continuous professional development.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 2 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    AACE has no control over allocating specific funding for maternity training.

    Verbatim wording from the response

    “With regard to under-graduate and post-graduate paramedic training we are aware of variation in the provision of training for paramedics in maternity care and breech birth in both Universities (accredited by the HCPC) and ambulance services which for qualified paramedics is the responsibility of individual ambulance trusts. Additionally, we do not have any control over the allocation of specific funding for maternity training. We are aware that some training is delivered face-to-face to staff, often supplemented by online modules, webinars, and instructional videos. Simulation and hands on practice are widely used with training covers both theoretical and practical skills. Refresher training varies with some services offering training every 1-4 years, annually or as a part of continuous professional development.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 2 · response
    Published 19 September 2025

    Open published response

  2. West Sussex

    AI-generated summary

    Arthur Ronnie TROTT · 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

    Arthur Ronnie Trott died four days after an unexpected footling breech delivery at home, following a delay in transfer to hospital; the report states that this materially contributed to severe hypoxic ischaemic encephalopathy and his death. Concerns included insufficiently robust emergency guidance for footling breech presentations and limited consultant midwife support, guidance and training across ambulance services.

    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

    Insufficient JRCALC guidance on emergency management of footling breech presentation

    Wider context from the report

    “1.The JRCALC guidance on the emergency management of footling breech presentation by the emergency services is insufficiently robust in that it should be recognised as different from other breech presentations and considered an acute obstetric emergency requiring immediate transfer to the nearest hospital obstetric unit. That is, no attempts should be made to attempt a home delivery due to difficulties with the baby's head not being able to be delivered. ”

    Source location

    Arthur Ronnie TROTT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    George French Russell · 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

    George French Russell was born prematurely at 35 weeks and 1 day following a footling breech birth on 11 January 2017, in poor condition and with severe brain damage. He died on 23 January 2017 after being transferred for neonatal care. Concerns included inadequate information-sharing between services and a lack of sustained expert input during the breech delivery.

    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 paramedic experience in managing footling breech deliveries

    Wider context from the report

    “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought. ”

    Source location

    George French Russell · Prevention of Future Deaths report
    Page 2 · 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 provide or seek continuing expert support during footling breech deliveries

    Wider context from the report

    “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought. ”

    Source location

    George French Russell · 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

    Develop standardised minimum criteria for requesting remote or on-scene obstetric support.

    Verbatim wording from the response

    “To ensure a more timely and objective Trust approach to community obstetric support EMAS has developed a standardised minimum criteria for requesting support from a remote service and from an on scene clinician. This is expected to be implemented in May 2018 subjected to governance processes. As an interim measure, guidance has been issued by clinical bulletin and to all relevant EOC staff.”

    Source location

    2018-0062-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 8 June 2018

    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

    Implement standardised minimum criteria for requesting remote or on-scene obstetric support.

    Verbatim wording from the response

    “To ensure a more timely and objective Trust approach to community obstetric support EMAS has developed a standardised minimum criteria for requesting support from a remote service and from an on scene clinician. This is expected to be implemented in May 2018 subjected to governance processes. As an interim measure, guidance has been issued by clinical bulletin and to all relevant EOC staff.”

    Source location

    2018-0062-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 8 June 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The HSIB cannot investigate this case because it occurred before the organisation became operational and falls outside its investigation criteria.

    Verbatim wording from the response

    “As you may be aware, the HSIB was set up to investigate systemic safety issues that cut across organisational boundaries. We conduct up to 30 investigations a year and focus on those with the most potential for new learning that have taken place after we became operational on 1st April, 2017. This case occurred before 1st April 2017 and therefore does not meet our criteria for investigation.”

    Source location

    2018-0062-Response-by-HSIB
    Page 1 · response
    Published 8 June 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operational concerns are for the involved NHS trusts to address.

    Verbatim wording from the response

    “Your report raises several areas of concern which are operational and for the NHS Trusts involved to address.”

    Source location

    2018-0062-Response-by-Department-of-Health
    Page 1 · response
    Published 8 June 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    HSIB cannot investigate incidents occurring before its establishment because they do not meet its investigation criteria.

    Verbatim wording from the response

    “I am aware that the HSIB has responded to you to advise that, as this incident occurred before its establishment on 1 April 2017, it does not meet the criteria for investigation. Nevertheless, the information provided will assist the HSIB develop a wider picture of safety issues in the NHS and help inform future investigations.”

    Source location

    2018-0062-Response-by-Department-of-Health
    Page 3 · response
    Published 8 June 2018

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026