2 Dec 2024 Elton Deutekom · Prevention of Future Deaths report Inner West London
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Concerns raised 10 Failure to disclose evidence relevant to deaths to the coroner under the duty of candor View source Insufficient supervision of newly qualified midwives managing women in labour View source Provision of assistance to write neonatal death records retrospectively View source Failure of neonatologists to pass sufficient and appropriate information to pathologists during consented post-mortem examinations View source Lack of a regular CTG review system on the central CTG monitoring board View source Failure to appropriately refer neonatal deaths to the coroner View source Failure of neonatologists to appropriately report deaths to the coroner View source Lack of Medical Examiner access to obstetric records when reviewing deaths View source Understaffing of the labour ward View source Destruction of contemporaneous handwritten notes following neonatal deaths View source See 7 more concerns
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.
View source
Action
Maintain Practice Development Midwife clinical support for preceptee midwives.
View source
Action
Ensure Medical Examiners review all neonatal deaths with access to maternal and obstetric records subject to consent and information-governance requirements.
View source
Action
Submit and consider a further maternity staffing investment business case following Phase 3 recruitment and the Birthrate Plus review.
View source
Action
Reiterate to neonatal and Trust leadership staff that concerns about a death should prompt referral to the Coroner.
View source
Action
Provide neonatal post-mortem clinicians with relevant clinical information through discharge summaries, request forms and direct discussion.
View source
Action
Introduce a night-shift safety coordinator on the Chelsea maternity site.
View source
Action
Update intrapartum fetal monitoring guidance to require bedside CTG confirmation and hourly holistic review with discussion between clinicians.
View source
Action
Review internal legal and governance processes to maintain clear records of disclosure.
View source
Action
Implement the enhanced NHSE midwifery preceptorship framework, including 150 hours of supernumerary status and protected progress meetings.
View source See 7 more actions
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AI-generated summary
Elton Deutekom · 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
Elton suffered acute hypoxic-ischaemic injury following a placental abruption during labour and was delivered by forceps at 04:35 on 12 January 2022; despite resuscitation, he was recognised as life extinct at 05:12. The report identifies failures to recognise and respond to abnormal CTG changes, and raises wider concerns about neonatal death referrals, disclosure of evidence, record-keeping, staffing, supervision and CTG monitoring.
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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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disclose evidence relevant to deaths to the coroner under the duty of candor
Wider context from the report “2. That Chelsea and Westminster hospital may not be complying with the duty of candor to disclose evidence relevant to a death to the coroner until forced to by court directions made in public , which thus raises the same concern as above.
” 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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient supervision of newly qualified midwives managing women in labour
Wider context from the report “5. That newly qualified midwives should have more supervision whilst they are managing women in labour .
” 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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Provision of assistance to write neonatal death records retrospectively
Wider context from the report “3. That following neonatal deaths assistance is given to midwifery staff as to how to write records in retrospect and contemporaneous handwritten notes are destroyed possibly reducing the accuracy of the records and thus risking that lessons may not be learned that may save the lives of others.
” 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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of neonatologists to pass sufficient and appropriate information to pathologists during consented post-mortem examinations
Wider context from the report “8. That the neonatologists at Chelsea and Westminster are not passing sufficient and appropriate information to the pathologists when consented post- mortem examinations occur such that the cause of death found by the pathologist may be inaccurate.
” 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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a regular CTG review system on the central CTG monitoring board
Wider context from the report “6. That there is no regular review system for CTGs on the central CTG monitoring board .
” 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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately refer neonatal deaths to the coroner
Wider context from the report “1. That Chelsea and Westminster Hospital are not appropriately referring neonatal deaths to coroner- either late or not at all , and this raises the possibility that lessons may not be learned from the investigation of these deaths that may save the lives of others.
” 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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of neonatologists to appropriately report deaths to the coroner
Wider context from the report “9. That neonatologists in other hospitals may not be appropriately reporting deaths to the coroner .
” 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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Medical Examiner access to obstetric records when reviewing deaths
Wider context from the report “7. That in some hospitals the Medical Examiners do not have access to obstetric records when reviewing deaths .
” 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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Understaffing of the labour ward
Wider context from the report “4. That the labour ward is understaffed .
” 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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Destruction of contemporaneous handwritten notes following neonatal deaths
Wider context from the report “3. That following neonatal deaths assistance is given to midwifery staff as to how to write records in retrospect and contemporaneous handwritten notes are destroyed possibly reducing the accuracy of the records and thus risking that lessons may not be learned that may save the lives of others.
” 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 Continue maternity workforce recruitment, retention and temporary staffing measures to address staffing gaps and improve safe capacity.
Verbatim wording from the response “The Trust has addressed the staffing gaps with an ongoing recruitment and retention programme.” Source location Response from Chelsea and Westminster 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 Maintain Practice Development Midwife clinical support for preceptee midwives.
Verbatim wording from the response “The Trust has investigated the levels of clinical support given to preceptee midwives and confirms that in practice, a Practice Development Midwife is allocated for clinical support, though this has been affected by staffing as posts are presently not fully recruited to.” Source location Response from Chelsea and Westminster 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 Ensure Medical Examiners review all neonatal deaths with access to maternal and obstetric records subject to consent and information-governance requirements.
Verbatim wording from the response “All deaths are now required to be reviewed under statutory duty of the Medical Examiner, therefore all neonatal deaths are reviewed. The Medical Examiners have confirmed that they have full access to maternal/obstetric notes as part of the review process and all access with them when appropriate consent has been obtained with regard to maternal records.” Source location Response from Chelsea and Westminster 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 Submit and consider a further maternity staffing investment business case following Phase 3 recruitment and the Birthrate Plus review.
Verbatim wording from the response “The Maternity service will be fully recruited to Phase 3 by March 2025. Following this, the Trust Executive Management Board and Finance Investment Committee will receive a business case for phase 4 (on the Chelsea Site this equates to 1 WTE clinical midwife and 1 WTE specialist and management), in addition to any proposed further investment following the Birth Rate Plus Review in April 2025. This will be to ensure we are at near-full capacity in terms of staffing. This funding has meant that the Maternity Unit has been able to lift the staffing in areas to improve safety, having put in a night shift safety coordinator on the Chelsea site. This was identified as learning within the Trust’s Action Plans. The Maternity team continue to use the NHSE funding for the preceptorship support midwife.” Source location Response from Chelsea and Westminster 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 Reiterate to neonatal and Trust leadership staff that concerns about a death should prompt referral to the Coroner.
Verbatim wording from the response “The Neonatal team liaise with the Medical Examiners and maternity teams in the event of a neonatal death and referrals are made appropriately and according to existing criteria.” Source location Response from Chelsea and Westminster 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 Provide neonatal post-mortem clinicians with relevant clinical information through discharge summaries, request forms and direct discussion.
Verbatim wording from the response “• In respect of evidentiary point 4, the neonatal consultant who obtains consent for the post mortem is expected to provide the discharge summary to the pathologist and/or complete a post mortem request form, in addition to speaking to them to highlight any relevant clinical information. We recognised that in this instance, on reviewing the summary there was no mention of the abruption. The consultant responsible is not able to confirm that the information relating to the abruption was subsequently passed on to the pathologist. The Trust apologises for this oversight and has taken this learning back to the Neonatal team to ensure all information identified at the time of the birth is provided as part of highlighting relevant clinical information.” Source location Response from Chelsea and Westminster 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 Introduce a night-shift safety coordinator on the Chelsea maternity site.
Verbatim wording from the response “The Maternity service will be fully recruited to Phase 3 by March 2025. Following this, the Trust Executive Management Board and Finance Investment Committee will receive a business case for phase 4 (on the Chelsea Site this equates to 1 WTE clinical midwife and 1 WTE specialist and management), in addition to any proposed further investment following the Birth Rate Plus Review in April 2025. This will be to ensure we are at near-full capacity in terms of staffing. This funding has meant that the Maternity Unit has been able to lift the staffing in areas to improve safety, having put in a night shift safety coordinator on the Chelsea site. This was identified as learning within the Trust’s Action Plans. The Maternity team continue to use the NHSE funding for the preceptorship support midwife.” Source location Response from Chelsea and Westminster 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 Update intrapartum fetal monitoring guidance to require bedside CTG confirmation and hourly holistic review with discussion between clinicians.
Verbatim wording from the response “This was accepted following on from the HSIB report and as a direct result of the recommendations, the Trust updated the current Intrapartum Fetal Monitoring Guideline to confirm that all CTG’s must be confirmed at a patient’s bedside. This is in line with the NICE Guidance and the Saving Babies Lives Care Bundle v3 that says a holistic review should take place hourly. The holistic review incorporates a categorisation of the CTG and requires a discussion between the midwife caring for the woman/birthing person and another midwife or doctor, which cannot be achieved at the central CTG monitoring screen, the outcome of this holistic review is discussed with the woman/birthing person. The CTG central monitoring screen can be a useful tool in supporting MDT discussions and teaching of fetal wellbeing.” Source location Response from Chelsea and Westminster 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 Review internal legal and governance processes to maintain clear records of disclosure.
Verbatim wording from the response “The Trust is reviewing its internal legal and governance processes to ensure clear records of disclosure are maintained so that we may provide assurance should the need arise in future.” Source location Response from Chelsea and Westminster 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 Implement the enhanced NHSE midwifery preceptorship framework, including 150 hours of supernumerary status and protected progress meetings.
Verbatim wording from the response “The new midwifery preceptorship framework published by NHSE in March 2023 was implemented at the Trust by September 2023 and remains in place. This current framework stipulates that all new starters should have supernumerary status for a minimum of 150 hours over a 12-month period, which usually means 75 hours at the start of each new rotation/area. The programme also strengthens the provision of protected time for preceptee/preceptor progress meetings and any additional support required.” Source location Response from Chelsea and Westminster NHS Foundation Trust
Open published response
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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 Trust disputes that the court was not provided with required evidence when requested, stating disclosure occurred before the inquest.
Verbatim wording from the response “It is denied that the court was not provided with the evidence it required when requested. As set out below, the Trust has confirmed that disclosure was made at the times requested prior to inquest, on 16 May 2023. Emails confirming this fact are enclosed for the attention of the Coroner. Despite this, the Trust appreciates that there were difficulties in establishing what had been disclosed and when during the hearing, and has fed this back internally.” Source location Response from Chelsea and Westminster NHS Foundation Trust
Open published response
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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 Current access to maternal and obstetric records within information governance processes is considered sufficient for Medical Examiner reviews; no Trust concern remains.
Verbatim wording from the response “7. That in some hospitals the Medical Examiners do not have access to obstetric records when reviewing deaths.” Source location Response from Chelsea and Westminster NHS Foundation Trust
Open published response
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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 statutory Medical Examiner reviews, referral criteria and multidisciplinary reviews are considered sufficient to ensure neonatal deaths are appropriately referred.
Verbatim wording from the response “The Trust is confident that it meets its obligations in respect of referring neonatal deaths to the Coroner.” Source location Response from Chelsea and Westminster NHS Foundation Trust
Open published response
24 Oct 2016 Hunter Jack Macmillan · Prevention of Future Deaths report West London
View report summary
Concerns raised 1 Insufficient Emergency Department staffing for treating suspected sepsis in accordance with national or local policy 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
Hunter Jack Macmillan · 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
Hunter Jack Macmillan was taken to the Emergency Department at West Middlesex Hospital after being booked into the Urgent Care Centre, but was not triaged for over 45 minutes as his condition deteriorated. The report raised concerns that staffing levels were insufficient to follow national or local policies for treating suspected sepsis.
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 Chelsea and Westminster Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient Emergency Department staffing for treating suspected sepsis in accordance with national or local policy
Wider context from the report “Staffing levels in the Emergency Department were not sufficient to be able to follow national (currently NICE Guideline, Sepsis:recognition, diagnosis and early management) or any local policy on treating suspected sepsis.
” 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