Recurring concern

Unreliable mode-of-delivery decision-making

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First reported 4 Apr 2016•Latest report 15 Sep 2023

Definition

What this concern includes

Includes failures in the dedicated maternity process for assessing, counselling, deciding and documenting the appropriate mode of delivery, including unchallenged presumptions, cost-driven influence, failure to account for material obstetric risks and inadequate discussion of the risks and benefits of vaginal birth or caesarean birth.

Not included

  • Excludes general pregnancy and birth risk-assessment failures where mode-of-delivery decision-making is not the material unsafe condition.
  • Excludes failures in intrapartum care, fetal monitoring or emergency obstetric escalation after the mode of delivery has been appropriately selected.
  • Excludes generic consent, communication or staffing deficiencies unless they directly impair an individualised and informed mode-of-delivery decision.
  • Excludes treatment or care-quality concerns unrelated to choosing, counselling about or documenting the mode of delivery.
Reports
7

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2016–2023

First to latest report issue date

Stated actions
5

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.

Department of Health and Social Care3
Gateshead Health NHS Foundation Trust1
George Eliot Hospital NHS Trust1
Luton and Dunstable University Hospital1
National Institute for Health and Care Excellence1
North Tyneside General Hospital1
Northumbria Healthcare NHS Foundation Trust1
Royal College of Midwives1
Royal College of Obstetricians and Gynaecologists1
Worcestershire Acute Hospitals NHS Trust1

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. Warwickshire

    AI-generated summary

    Eclipse Morrison · 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

    Eclipse Morrison died at Nottingham City Hospital on 21 July 2021, the day after her birth, following perinatal asphyxia and complications associated with gestational diabetes, excessive fetal growth and shoulder dystocia. The principal concerns included failures to follow up missed appointments, consider and discuss appropriate timing and mode of delivery, identify risk factors during labour, and ensure adequate fetal monitoring. Further concerns related to the implementation and quality assurance of Badgernet, escalation procedures for ultrasound concerns, counselling about shoulder dystocia, and interpretation of Montgomery 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

    Failure to ensure appropriate timing and mode of delivery in high-risk pregnancies

    Wider context from the report

    “1. Risk analysis / mode and timing of birth A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved. Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified. Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant. I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors. I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums. I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs. It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy. It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth. The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies. ”

    Source location

    Eclipse Morrison · 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 counselling supporting fully informed mode-of-delivery decisions where there is risk of shoulder dystocia

    Wider context from the report

    “5. Counselling for mothers at increased risk of shoulder dystocia I have not seen any indication that all mothers identified to have an increased chance of shoulder dystocia now receive counselling regarding the risks and benefits associated with vaginal birth or CS. Assisting mothers to understand the implications of risks they face is fundamental to supporting them to make fully informed decisions, in accordance with Montgomery. The concern remains that there is no clear plan in place to ensure mothers receive the support they require to make fully informed decisions in relation to mode of delivery where there is risk of shoulder dystocia. ”

    Source location

    Eclipse Morrison · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Worcestershire

    AI-generated summary

    RHIAN EMMA KATE ROSE · 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

    Rhian Rose became unwell during a hospital admission for the second phase of medical termination of pregnancy following feticide for trisomy 21. Her condition deteriorated, leading to emergency caesarean section, hysterectomy and cardiac arrest; she died from multi-organ failure and sepsis on 25 November 2019. The principal concerns were insufficient consideration of informed consent and maternal choice regarding mode of delivery, and inadequate guidance on infection risks and delivery options following feticide.

    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 record discussions about mode of delivery, maternal wishes and management-plan risks and benefits

    Wider context from the report

    “1) Informed consent and material choice regarding mode of delivery – I am concerned that enough emphasis is not being given to maternal wishes regarding mode of delivery. This issue appears to be a recurring theme in obstetric practice, and I am concerned that the culture in this area appears to still not fully accepting of the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section) and of facilitating the wishes of pregnant women and holding full and frank discussions about the risks and benefits and the pros and cons of the different options. I am concerned that situations might arise, like it appeared happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health. Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussions held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk/benefits of differing management plans. ”

    Source location

    RHIAN EMMA KATE ROSE · 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 informed consent discussions and facilitate maternal wishes regarding mode of delivery

    Wider context from the report

    “1) Informed consent and material choice regarding mode of delivery – I am concerned that enough emphasis is not being given to maternal wishes regarding mode of delivery. This issue appears to be a recurring theme in obstetric practice, and I am concerned that the culture in this area appears to still not fully accepting of the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section) and of facilitating the wishes of pregnant women and holding full and frank discussions about the risks and benefits and the pros and cons of the different options. I am concerned that situations might arise, like it appeared happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health. Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussions held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk/benefits of differing management plans. ”

    Source location

    RHIAN EMMA KATE ROSE · 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

    Adopt the IDECIDE tool in the maternity information system to support and document informed mode-of-delivery decisions.

    Verbatim wording from the response

    “The IDECIDE tool has already been built into the BadgerNet maternity information system, however NHSX has asked that CleverMed to hold off on making this available to sites in the live BadgerNet mode. NHSX want to ensure other vendors have the opportunity to create a version, and are working on taking the design CleverMed have created into a more generic specification. CleverMed have asked NHSX for a timescale of when they could start a pilot or involve BadgerNet sites however this has yet to be agreed.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 2 · response
    Published 4 November 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

    Introduce personalised care plans in the BadgerNotes app for discussion, review and professional authorisation.

    Verbatim wording from the response

    “C) Personalised care plans are being introduced at WHAT in January 2022, this will give women the ability to complete a birth plan within their BadgerNotes app, the plan must be discussed, reviewed and authorised by a Healthcare professional.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · response
    Published 4 November 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

    Provide monthly multidisciplinary maternity training covering human factors, informed consent, Montgomery, balanced counselling and documentation.

    Verbatim wording from the response

    “D) Training at WAHT in maternity is multi professional and this takes place on a monthly basis. Included within this a section is dedicated to human factors, Informed consent and reference is made to the Montgomery ruling and balanced counselling and documentation. This case highlighted the importance of contemporaneous documentation regarding mode of delivery discussions and decisions.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · response
    Published 4 November 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

    Establish and audit a robust process for managing requests for Caesarean Section during labour.

    Verbatim wording from the response

    “E) Following the Ockenden Review, one of the immediate essential actions is for review of management of maternal request for Caesarean Section for both elective cases and during labour. This is a challenge for all maternity units across the country and is a matter being considered carefully by the Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM). The trust performance and progress with this action will be monitored via the Local Maternity & Neonatal System (LMNS) as part of the National Perinatal Quality Surveillance tool. In the first review by NHSEI the trust have received an amber rating for this as we do not currently have a robust audit process for “in labour” requests for Caesarean Section. Our initial action to improve this position would be to develop an achievable process and to appoint an ‘Audit & Guideline Midwife’.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · response
    Published 4 November 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

    Appoint an Audit and Guidelines Midwife to support Caesarean-request process development and audit.

    Verbatim wording from the response

    “E) Following the Ockenden Review, one of the immediate essential actions is for review of management of maternal request for Caesarean Section for both elective cases and during labour. This is a challenge for all maternity units across the country and is a matter being considered carefully by the Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM). The trust performance and progress with this action will be monitored via the Local Maternity & Neonatal System (LMNS) as part of the National Perinatal Quality Surveillance tool. In the first review by NHSEI the trust have received an amber rating for this as we do not currently have a robust audit process for “in labour” requests for Caesarean Section. Our initial action to improve this position would be to develop an achievable process and to appoint an ‘Audit & Guideline Midwife’.”

    Source location

    2021-0371-Response-from-Worcestershire-Acute-Hospitals-Trust_Published
    Page 3 · response
    Published 4 November 2021

    Open published response

  3. Sunderland

    AI-generated summary

    Vinnie William Ord Dodds · 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

    Vinnie William Ord Dodds died at Sunderland Royal Hospital on 14 April 2020 after major shoulder dystocia was recognised following a forceps delivery; he could not be successfully resuscitated. The concerns related to antenatal care, including the lack of national guidance for managing large babies, the content of counselling about shoulder dystocia risks, the timing of glucose tolerance testing, and the omission of the risk of death from shoulder dystocia in current patient information.

    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 counselling about fatal risks associated with shoulder dystocia

    Wider context from the report

    “Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic. The Trust carried out and acted on a full review. However, there are concerns of wider significance: - 1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present, so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby. a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks? b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)? c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise. 2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks? 3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013). ”

    Source location

    Vinnie William Ord Dodds · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Newcastle upon Tyne

    AI-generated summary

    Maia Hazel Ann Strachan · 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

    Maia Hazel Ann Strachan was born on 6 July 2017 and died in hospital on 7 July 2017 after a complicated delivery involving shoulder dystocia, hypoxic ischaemic encephalopathy and severe macrosomia. The report identified concerns about inaccurate and suboptimal ultrasound assessment, inaccessible obstetric and diabetic records, missed opportunities for Caesarean delivery and joint decision-making, fetal scalp electrode use, documentation, and dissemination of expert findings.

    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 provide advice and explanations for informed pregnancy and delivery decisions

    Wider context from the report

    “(3) Joint Decision Making: - Provision of advice and explanation of the risks of pregnancy and the risks/benefits of vaginal delivery or by Caesarean Section are essential to ensure informed decision making. The Trust should draft and implement a clear and comprehensive Local Joint Decision Making Policy/Protocol. ”

    Source location

    Maia Hazel Ann Strachan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Gateshead and South Tyneside

    AI-generated summary

    ARCHIE RAY GRIEVES · 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

    Archie Ray Grieves was born on 24 May 2017 following a complicated delivery involving shoulder dystocia. He initially showed no signs of life, later showed signs of life, and died a short time after being taken to the special care baby unit. The report identified an avoidable neonatal death, with an eight-minute delay in delivering his body after his head and missed opportunities during antenatal care and delivery to identify risks and plan a safe birth.

    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 plan and counsel on timing and mode of delivery for suspected larger babies

    Wider context from the report

    “8. No additional planning for pre delivery/delivery was engaged and this mother was continued on a normal pathway towards delivery apparently planned between the 40th and 42nd week. 9. In the absence of Obstetric care effective planning opportunities were missed to consult and counsel this mother on the mode and time of delivery. In particular no consideration was given to the possibility of an induced or caesarean birth or delivery of this child at the 37th/38th week avoiding increases in baby’s weight and recognisable risks at the time of delivery of a larger baby. ”

    Source location

    ARCHIE RAY GRIEVES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Bedfordshire and Luton

    AI-generated summary

    Albie Henderson Marlow · 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

    Albie Henderson Marlow was delivered by Category 2 Caesarean Section at 37 weeks’ gestation and was recorded as stillborn, although the family stated that he cried. The principal concern was that the mother’s requests for Caesarean delivery during labour were not respected, with the report stating that this placed babies’ lives at risk.

    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 respect mothers' requests for Caesarean Section delivery

    Wider context from the report

    “During the course of the Inquiry into the death of Baby Albie I heard that throughout labour his mother had asked for, and indeed, "begged" for a Caesarean Section delivery and her wish was not granted. She expressed concern that the delivery was following the same pattern as an earlier pregnancy and it had resulted in a delivery by emergency C Section. It was apparent that if baby Albie had been delivered when mother requested a C section he would have survived. My concern is that mothers requesting delivery by Caesarean Section are not having their wishes respected and this is putting babies' lives at risk. ”

    Source location

    Albie Henderson Marlow · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Existing policies, guidelines, specialist counselling and individualised care plans are considered sufficient to support maternal Caesarean-choice requests while maintaining safety.

    Verbatim wording from the response

    “Unfortunately as not all of the respective clinicians directly involved in the delivery of care were called to attend the hearing and as live evidence on the discussion held with the respective disciplines of staff involved were not heard, we are confident the information contained in this response will reassure HM Senior Coroner respectfully that the Luton & Dunstable University Hospital NHS Trust does have policies and processes in place for mother’s requesting caesarean sections and our staff are skilled to understand and empower women of their right to choose for themselves whilst ensuring that the safety of mothers and infants remains paramount.”

    Source location

    2017-0015-Response-by-Luton-and-Dunstable-University-Hospital
    Page 1 · response
    Published 19 February 2017

    Open published response

  7. North London

    AI-generated summary

    Kristian Andrew Jaworski · 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

    Kristian Andrew Jaworski was born following a prolonged instrumental delivery involving ventouse and forceps, followed by an emergency caesarean section. He was born with poor Apgar scores and died five days later; the report identified a concern that vaginal delivery was presumed partly on the basis of cost.

    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 rebut a cost-based presumption in favour of vaginal delivery

    Wider context from the report

    “That there was a presumption in favour of vaginal delivery based partly of cost that needed to be rebutted. ”

    Source location

    Kristian Andrew Jaworski · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 Department cannot comment on why caesarean delivery was not attempted earlier or whether cost influenced that decision.

    Verbatim wording from the response

    “I am unable to comment on why a caesarean delivery was not attempted at an earlier opportunity in this case or whether that decision was based in any way on cost – this is clearly something that the North Middlesex University Hospital NHS Trust needs to consider. I will ensure that a copy of your letter and this reply are sent to the Trust to give them the opportunity to respond to your concern.”

    Source location

    2016-0125-Response-by-Department-of-Health
    Page 2 · response
    Published 4 April 2016

    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 hospital trust must consider why caesarean delivery was not attempted earlier and whether cost influenced that decision.

    Verbatim wording from the response

    “I am unable to comment on why a caesarean delivery was not attempted at an earlier opportunity in this case or whether that decision was based in any way on cost – this is clearly something that the North Middlesex University Hospital NHS Trust needs to consider. I will ensure that a copy of your letter and this reply are sent to the Trust to give them the opportunity to respond to your concern.”

    Source location

    2016-0125-Response-by-Department-of-Health
    Page 2 · response
    Published 4 April 2016

    Open published response
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Data last updated 7 September 2026