Recipient

Airedale NHS Foundation Trust

First report 30 Jul 2018•Latest report 2 Dec 2024

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

Naming this recipient

Published responses
150%

Found for named reports

Concerns addressed
5

Across all linked responses

Stated actions
24

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

150%published responses found
24stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Airedale NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Yorkshire (Western)

    AI-generated summary

    Alfie HINTON · 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

    Baby Alfie Hinton died at Airedale Hospital on 10 May 2019 after complete umbilical cord occlusion led to hypoxic ischaemic brain injury. The report describes delays in induction, fetal monitoring, recognition of bradycardia and preparations for birth. Concerns included how maternal risk information was gathered, recorded and communicated, communication between consultants, and the absence of local policy for time-critical situations.

    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. The report was sent to Airedale NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of communication between consultant obstetric and anaesthetic staff in time critical situations

    Wider context from the report

    “(2) During the course of the Inquest, I heard evidence about the difficulties in communication between the Consultant Obstetrician and Consultant Anaesthetist, with delays being caused by several attempts being made at sitting spinal anaesthetic, against the advice of the Obstetrician and the wishes of the patient, causing distress to staff and patient alike. I heard no evidence of any policy that provided direction or guidance in circumstances such as this. This gives rise to concerns in respect of communication, ongoing risk assessment and an absence of local policy in respect of the approach to be taken in such time critical situations. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Airedale NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to assess maternal risks following admission

    Wider context from the report

    “(1) During the course of the Inquest, I could find no evidence of how or if the maternal risks were assessed following her admission, nor how the level of risk posed by the level of bile acids was communicated to those tasked with prioritising those patients awaiting induction of labour and therefore the allocation of staffing and resources. This is further reflected in the 39 minute delay in CTG monitoring and the fact that at the point Bradycardia was noted, the initial assumption from staff was that there was an issue with the monitoring equipment, there being little awareness of the risks already present, which contributed to delays in expediting delivery. These facts give rise to concerns in respect of the way in which information is gathered and shared within the Maternity Unit and in particular how risk is recorded and communicated between all of those involved in providing intrapartum care. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Airedale NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of local policy directing the approach to time critical obstetric and anaesthetic situations

    Wider context from the report

    “(2) During the course of the Inquest, I heard evidence about the difficulties in communication between the Consultant Obstetrician and Consultant Anaesthetist, with delays being caused by several attempts being made at sitting spinal anaesthetic, against the advice of the Obstetrician and the wishes of the patient, causing distress to staff and patient alike. I heard no evidence of any policy that provided direction or guidance in circumstances such as this. This gives rise to concerns in respect of communication, ongoing risk assessment and an absence of local policy in respect of the approach to be taken in such time critical situations. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Airedale NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to gather, record and communicate intrapartum risk information

    Wider context from the report

    “(1) During the course of the Inquest, I could find no evidence of how or if the maternal risks were assessed following her admission, nor how the level of risk posed by the level of bile acids was communicated to those tasked with prioritising those patients awaiting induction of labour and therefore the allocation of staffing and resources. This is further reflected in the 39 minute delay in CTG monitoring and the fact that at the point Bradycardia was noted, the initial assumption from staff was that there was an issue with the monitoring equipment, there being little awareness of the risks already present, which contributed to delays in expediting delivery. These facts give rise to concerns in respect of the way in which information is gathered and shared within the Maternity Unit and in particular how risk is recorded and communicated between all of those involved in providing intrapartum care. ”
    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 Human Factors and Ergonomics Training Workshops led by a consultant anaesthetist to address systems and behavioural influences on outcomes.

    Verbatim wording from the response

    “6. As explained in evidence to the Inquest, the Trust has developed a programme of Human Factor and Ergonomics Training Workshops, led by a Consultant Anaesthetist, which focuses on systems issues within healthcare and how human behaviours influence outcome and can be modified through systems changes to achieve better clinical outcomes (the principles of such training are explained at Human factors | NHS England | Workforce, training and education).”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 9 · response
    Published 2 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

    Update the Obstetric Cholestasis Guideline with bile-acid-specific delivery timing and urgent senior review requirements for severe disease.

    Verbatim wording from the response

    “1. I can advise that the Obstetric Cholestasis Guideline has been further updated to reflect the updated RCOG green topped guideline. This included guidance on the timing of delivery relating to the specific level of the bile acid results. The guideline states diagnosis of severe ICP would prompt delivery between 35-36 weeks. Diagnosis of severe ICP after 36 weeks would require immediate senior obstetric review and Induction of Labour and the guideline now makes this clear.”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 5 · response
    Published 2 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

    Embed simulation-based training using obstetric emergencies, incidents, case reviews and patient experience to improve emergency teamwork and learning.

    Verbatim wording from the response

    “3. As explained in evidence to the Inquest, the Trust has embedded SIMS training – real life Simulation Based Training which is based on obstetric emergencies and scenarios. This is a learning tool used to improve team working in emergency procedures. The SIMS training includes learning from scenarios, incidents, case reviews, patients’ experience and themes and trends across the service to improve learning and reflection. This facilitates constructive feedback to aid teams working together, learning from scenarios and dynamic integration into current themes on the maternity unit.”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 8 · response
    Published 2 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

    Strengthen the anaesthesia guideline for Category 1 caesarean sections, including five-minute multidisciplinary review and conversion to general anaesthesia where appropriate.

    Verbatim wording from the response

    “The Guideline was revised post Alfie’s case (March 2020 and again in October 2023) and the relevant sections (taken from the version created in October 2023) state:”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 6 · response
    Published 2 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

    Embed multidisciplinary PROMPT training for anaesthetists, obstetricians and midwives using an evidence-based human-factors approach.

    Verbatim wording from the response

    “As part of an organic development in health practice but also designed specifically to address the issues which occurred in this present case, particularly focussed on culture, leadership, team working and compliance with national standards, the Trust undertook the following:”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 8 · response
    Published 2 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

    Develop a risk-based RAG rating system to standardise prioritisation of induction-of-labour cases.

    Verbatim wording from the response

    “2. The prioritisation process and proforma formalises the process of patient management and priority according to individualised patient risk and provides a living record of priority to evidence why one patient is scored above another. It reflects MDT agreement as to priority.”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 5 · response
    Published 2 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

    Create and publish an induction-of-labour process map covering activity assessment, escalation, safeguards against delay and multidisciplinary prioritisation.

    Verbatim wording from the response

    “Process – Induction of Labour Management”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 5 · response
    Published 2 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

    Implement an Induction of Labour Prioritisation Proforma to record risks, prioritisation decisions, multidisciplinary agreement and delays.

    Verbatim wording from the response

    “It was however explained in evidence that as a result of the events in this case and in response to the Healthcare Safety Investigation Branch (‘HSIB’) independent investigation into the circumstances of this case, the Trust has developed and implemented an Induction of Labour Prioritisation Proforma, to highlight risks and associated priority of women attending for induction of labour. The Trust supplied the Coroner with the proforma and this details the following guidance:”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 4 · response
    Published 2 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

    Create and publish a Category 1 caesarean section and fetal bradycardia process map covering escalation, anaesthetic decisions, effective anaesthesia and delivery timelines.

    Verbatim wording from the response

    “Process – Category 1 Caesarean Section / Fetal Bradycardia”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 8 · response
    Published 2 December 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

    Existing records, handovers, ward rounds, SBAR communication and coordinator oversight were relied upon to communicate risk and prioritise inductions.

    Verbatim wording from the response

    “As to the specific issue of how risk factors are communicated, every expectant mother admitted to the maternity unit would be under the care of an obstetric consultant and/or midwife and those clinicians would bear responsibility for knowing the patient’s history and presentation and to review and complete the patient’s record, which would contain all such information.”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 3 · response
    Published 2 December 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 delay in commencing induction was considered reasonable because unit activity prevented accommodating the patient earlier.

    Verbatim wording from the response

    “We also observe at this stage that LW Coordinator, BB, gave evidence to the inquest to the effect that she was fully aware of Mrs Hinton and her clinical condition throughout the day shift of 09.05.19 and that she was communicating with the Obstetric Consultant with regards to patient acuity on the unit to determine the point at which it was safe to offer Mrs Hinton IOL, which was agreed shortly after 18:00 hours on 09.05.19.”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 4 · response
    Published 2 December 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 case was not considered to require emergency caesarean delivery at admission, a view supported by independent reviews.

    Verbatim wording from the response

    “In Mrs Hinton’s case, on 08.05.19, it was promptly recognised by the admitting Consultant Obstetrician that her bile acids were very significantly elevated and that she was suffering from Obstetric Cholestasis.”

    Source location

    Response from Airedale NHS Foundation Trust
    Page 2 · response
    Published 2 December 2024

    Open published response
  2. West Yorkshire (Western)

    AI-generated summary

    Stanford Shirley Bell · 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

    Stanford Shirley Bell, who had dementia, fell at Riverview Nursing Home on 22 February 2018 and later died on 2 March 2018 after suffering seizures and an acute on chronic subdural haematoma. Concerns included the absence of hospital discharge papers and written neurological-observation recommendations, and delayed referral from the care home after seizures following head trauma.

    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. The report was sent to Airedale NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of discharge papers for patients neurologically assessed with head injuries

    Wider context from the report

    “For Airedale Hospital to review procedures at hospital discharge with respect to patients neurologically assessed with head injuries given the absence of discharge papers ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Airedale NHS Foundation Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of care-home referral procedures for patients suffering seizures after recently sustained head trauma

    Wider context from the report

    “For Riverview Care home to review procedures at the care home with respect to referral to hospital of patients suffering from seizures after a recently sustained head trauma. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

150%
150%All other recipients 58%
0%100%

How actions were described at the time

This respondent
71%25%4%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026