2 Dec 2024 Alfie HINTON · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 4 Failure of communication between consultant obstetric and anaesthetic staff in time critical situations View source Failure to assess maternal risks following admission View source Absence of local policy directing the approach to time critical obstetric and anaesthetic situations View source Failure to gather, record and communicate intrapartum risk information View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Develop Human Factors and Ergonomics Training Workshops led by a consultant anaesthetist to address systems and behavioural influences on outcomes.
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Action
Update the Obstetric Cholestasis Guideline with bile-acid-specific delivery timing and urgent senior review requirements for severe disease.
View source
Action
Embed simulation-based training using obstetric emergencies, incidents, case reviews and patient experience to improve emergency teamwork and learning.
View source
Action
Strengthen the anaesthesia guideline for Category 1 caesarean sections, including five-minute multidisciplinary review and conversion to general anaesthesia where appropriate.
View source
Action
Embed multidisciplinary PROMPT training for anaesthetists, obstetricians and midwives using an evidence-based human-factors approach.
View source
Action
Develop a risk-based RAG rating system to standardise prioritisation of induction-of-labour cases.
View source
Action
Create and publish an induction-of-labour process map covering activity assessment, escalation, safeguards against delay and multidisciplinary prioritisation.
View source
Action
Implement an Induction of Labour Prioritisation Proforma to record risks, prioritisation decisions, multidisciplinary agreement and delays.
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Action
Create and publish a Category 1 caesarean section and fetal bradycardia process map covering escalation, anaesthetic decisions, effective anaesthesia and delivery timelines.
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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.
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× 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
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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
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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
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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
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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
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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
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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
Open published response
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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
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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
Open published response
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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
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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
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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
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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
Open published response
30 Jul 2018 Stanford Shirley Bell · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Absence of discharge papers for patients neurologically assessed with head injuries View source Failure of care-home referral procedures for patients suffering seizures after recently sustained head trauma View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations