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
13
Across all linked responses
Stated actions
22
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
22stated actions described
Topic comparisons are not available in the current evidence snapshot.
Concerns and recipient responses
Statements from Chelsea and Westminster Hospital NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.
Inner West London
Concerns raised10
Failure to disclose evidence relevant to deaths to the coroner under the duty of candor
Insufficient supervision of newly qualified midwives managing women in labour
Provision of assistance to write neonatal death records retrospectively
Failure of neonatologists to pass sufficient and appropriate information to pathologists during consented post-mortem examinations
Lack of a regular CTG review system on the central CTG monitoring board
Failure to appropriately refer neonatal deaths to the coroner
Failure of neonatologists to appropriately report deaths to the coroner
Lack of Medical Examiner access to obstetric records when reviewing deaths
Understaffing of the labour ward
Destruction of contemporaneous handwritten notes following neonatal deaths
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.10
Action
Continue maternity workforce recruitment, retention and temporary staffing measures to address staffing gaps and improve safe capacity.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 December 2024.
Action
Maintain Practice Development Midwife clinical support for preceptee midwives.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 December 2024.
Action
Ensure Medical Examiners review all neonatal deaths with access to maternal and obstetric records subject to consent and information-governance requirements.
Stated completedThe respondent said that this action was complete when they made their response on 3 December 2024.
Action
Submit and consider a further maternity staffing investment business case following Phase 3 recruitment and the Birthrate Plus review.
Stated plannedThe respondent said that this action was planned when they made their response on 3 December 2024.
Action
Reiterate to neonatal and Trust leadership staff that concerns about a death should prompt referral to the Coroner.
Stated completedThe respondent said that this action was complete when they made their response on 3 December 2024.
Action
Provide neonatal post-mortem clinicians with relevant clinical information through discharge summaries, request forms and direct discussion.
Stated completedThe respondent said that this action was complete when they made their response on 3 December 2024.
Action
Introduce a night-shift safety coordinator on the Chelsea maternity site.
Stated completedThe respondent said that this action was complete when they made their response on 3 December 2024.
Action
Update intrapartum fetal monitoring guidance to require bedside CTG confirmation and hourly holistic review with discussion between clinicians.
Stated completedThe respondent said that this action was complete when they made their response on 3 December 2024.
Action
Review internal legal and governance processes to maintain clear records of disclosure.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 December 2024.
Action
Implement the enhanced NHSE midwifery preceptorship framework, including 150 hours of supernumerary status and protected progress meetings.
Stated completedThe respondent said that this action was complete when they made their response on 3 December 2024.
Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.3
Position
The Trust disputes that the court was not provided with required evidence when requested, stating disclosure occurred before the inquest.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Current access to maternal and obstetric records within information governance processes is considered sufficient for Medical Examiner reviews; no Trust concern remains.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing statutory Medical Examiner reviews, referral criteria and multidisciplinary reviews are considered sufficient to ensure neonatal deaths are appropriately referred.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West London
Concerns raised1
Insufficient Emergency Department staffing for treating suspected sepsis in accordance with national or local policy
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations