Recurring concern

Unreliable major haemorrhage response arrangements

First to latest report 21 Jul 2015 — 13 Dec 2024

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

What this concern includes

Includes failures in the dedicated major-haemorrhage response process, including recognition and activation thresholds, protocol and pathway operation, access to blood products and urgent testing, staffing, equipment, communication, escalation and assurance of the response across relevant clinical settings.

What is not included
  • Excludes general bleeding-management deficiencies where no major-haemorrhage response process is identified.
  • Excludes routine blood-product storage, transfusion or laboratory delays unrelated to an activated or potentially indicated major-haemorrhage response.
  • Excludes obstetric, trauma or other condition-specific care failures where the major-haemorrhage response process is not the deficient control.
  • Excludes failures occurring after a major-haemorrhage response has operated reliably when the remaining issue is unrelated downstream treatment.

Reports and published responses 5 reports

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

  1. Essex

    AI-generated summary

    LAURA-JANE KIRSTEN NICOLE SEAMAN · 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

    Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.

    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 trigger the major haemorrhage protocol

    Wider context from the report

    “(1) The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023 c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts d. Communication issues with Trust staff and sharing of information e. Lack of compliance with national guidance and training f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient g. Lack of compliance with the triggering of the major haemorrhage protocol ”

    Source location

    LAURA-JANE KIRSTEN NICOLE SEAMAN · 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

    Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.

    Verbatim wording from the response

    “The RCOG’s clinical guidance in this context includes the following:”

    Source location

    Response from Royal College of Obstetricians and Gynaecologists
    Page 3 · response
    Published 18 December 2024

    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 guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.

    Verbatim wording from the response

    “5. Good Practice Paper on Roles and responsibilities of the consultant providing acute care in obstetrics and gynaecology⁹ states that one of the general situations in which the consultant must attend is any return to theatre for obstetrics or gynaecology. Some of the other obstetrics reasons for attendance are early warning score protocol or sepsis screening tool that suggests critical deterioration where HDU / ITU care is likely to become necessary or maternal collapse or where ‘major obstetric haemorrhage’ call has been instigated.”

    Source location

    Response from Royal College of Obstetricians and Gynaecologists
    Page 4 · response
    Published 18 December 2024

    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

    Address major-haemorrhage protocol compliance through education, training, amended guidance and monthly monitoring.

    Verbatim wording from the response

    “Although this concern was not specifically drawn out in the initial Rapid Review, the HSIB report highlighted this as a safety action which has now been addressed through education, training, and the amendment of local guidance.”

    Source location

    Response from Mid & South Essex NHS Trust
    Page 6 · response
    Published 18 December 2024

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    James Patrick PEARSON · 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

    James Pearson was struck by a vehicle on 14 June 2023 and later died at a hospice on 22 October 2023 after sustaining traumatic and hypoxic brain injuries, developing pneumonia, and experiencing a prolonged hospital admission. The concerns included undocumented observations, insufficient doctor coverage during his deterioration, and the time needed to obtain blood products; the report also states that an opportunity to provide fluids was missed and that this would probably have prevented his cardiac arrest and subsequent hypoxic brain injury.

    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

    Delays in obtaining blood products after major haemorrhage protocol activation

    Wider context from the report

    “9. I further heard from ████████ that the blood products at Birmingham Heartlands Hospital are not kept in the ED, and are kept some distance away, and could take up to 20 minutes to obtain after the major haemorrhage protocol is activated. Whilst this is unlikely to have affected the outcome for James, due to his sudden deterioration, I am concerned that a delay in obtaining blood products could lead to future deaths. ”

    Source location

    James Patrick PEARSON · 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

    Audit compliance with the Major Haemorrhage Blood Protocol across all UHB sites.

    Verbatim wording from the response

    “A review of all incidents involving activation of the MHP within Heartlands Emergency Department since Mr Pearson’s death has been undertaken. This did not demonstrate any incidents regarding delays in receipt of blood once the MHP was activated. A full audit is underway by the Hospital Transfusion Group to review overall compliance to the Major Haemorrhage Blood Protocol across all UHB sites, the outcome of this will be reported to the Trust Transfusion Committee.”

    Source location

    Response from University Hospitals Birmingham
    Page 3 · response
    Published 20 May 2024

    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

    A blood fridge is not being provided because group O blood is nationally scarce and Heartlands is not a Major Trauma Centre.

    Verbatim wording from the response

    “The recommendation to consider a blood fridge in BHH ED has been discussed in the Hospital Transfusion team. There are significant consequences to putting a fridge in the ED at BHH, not least that group O blood (which is what would need to be in the fridge if it is being used to support immediate transfusion) is in short supply nationally and needs to be used only for those patients that require it. This includes not stocking it in locations where it is unlikely to be used, which includes EDs (such as Heartlands) which are not in Major Trauma Centres.”

    Source location

    Response from University Hospitals Birmingham
    Page 3 · response
    Published 20 May 2024

    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 blood arrived within 15 minutes after major haemorrhage protocol activation, so the relevant delay was in requesting blood and activating the protocol.

    Verbatim wording from the response

    “Availability of blood products within the emergency department You heard evidence that it can take up to 20 minutes to obtain blood products within the emergency department following activation of the major haemorrhage protocol. Whilst this delay was unlikely to have affected the outcome for Mr Pearson, you are concerned that delays in blood products being available could result in future deaths.”

    Source location

    Response from University Hospitals Birmingham
    Page 3 · response
    Published 20 May 2024

    Open published response

  3. North Wales (East and Central)

    AI-generated summary

    Vivienne Greener · 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

    Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.

    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 clarity about when to engage the Major Haemorrhage Pathway

    Wider context from the report

    “5. There is not a clear understanding of when the Major Haemorrhage Pathway should be engaged; ”

    Source location

    Vivienne Greener · Prevention of Future Deaths report
    Page 4 · 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

    Display the Major Haemorrhage Pathway in all clinical areas, including the Emergency Department resuscitation area.

    Verbatim wording from the response

    “Any member of staff can trigger the Major Haemorrhage Pathway and it is printed on the wall in all clinical areas, including the resuscitation area in ED, and is clearly visible to all. Senior staff who are all very familiar with the pathway are always available and support all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the pathway.”

    Source location

    Response from Betso Cadwaladr University Health Board
    Page 5 · response
    Published 28 December 2023

    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 Major Haemorrhage Pathway is available to all staff, visibly displayed, and supported by experienced senior staff.

    Verbatim wording from the response

    “Any member of staff can trigger the Major Haemorrhage Pathway and it is printed on the wall in all clinical areas, including the resuscitation area in ED, and is clearly visible to all. Senior staff who are all very familiar with the pathway are always available and support all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the pathway.”

    Source location

    Response from Betso Cadwaladr University Health Board
    Page 5 · response
    Published 28 December 2023

    Open published response

  4. Derby and Derbyshire

    AI-generated summary

    Rachael Chloe WALKER · 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

    Rachael Chloe Walker died in hospital on 19 June 2021 after a placental haemorrhage and amniotic fluid embolism at 37 weeks of pregnancy. The report identified missed opportunities involving the recording and implementation of an earlier delivery plan and national guidance. The principal concern was whether the Trust had sufficiently robust processes for updating clinical guidance and ensuring essential equipment and procedures were in place.

    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 test the procedure for calling and responding to a major maternal haemorrhage

    Wider context from the report

    “My principal concern is that having heard evidence from the Trust as to ‘lessons learnt’ and its current processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, I remain unclear that the Trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of Chloe. Indeed, I am unclear that the processes are substantively different to those that existed at the time of Chloe’s death. It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into Trust policy and guidance. I was told that introducing revised guidance was necessarily complex and lengthy and yet the Trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the Trust had established a regional pregnancy service using out of date guidance. Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process; for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest. I therefore consider that the Trust should review its processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the interests of preventing future deaths, and that those processes should ensure timely revisions and associated actions. ”

    Source location

    Rachael Chloe WALKER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Gwent

    AI-generated summary

    Rachel Hollister · 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

    Rachel Hollister died after suffering a cardiac arrest during surgery for removal of a retained placenta following childbirth at the Royal Gwent Hospital on 13 April 2013. Concerns included staff and porters not following or being unaware of Health Board protocols, and the major obstetric haemorrhage protocol not meeting published guidelines.

    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

    Major obstetric haemorrhage protocol failing to meet published clinical guidelines

    Wider context from the report

    “2. The major obstetric haemorrhage protocol does not meet the guidelines published by the Royal College of Obstetricians and Gynaecologists ”

    Source location

    Rachel Hollister · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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