24 Jul 2019 Xander Curran-Pass · Prevention of Future Deaths report Manchester South
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Concerns raised 10 Lack of guidance on pethidine use with significant reduced fetal movement View source Inconsistent fundal-height measurement and recording View source Lack of national provision for sharing maternity induction-of-labour learning View source Poor quality of admission documentation View source Failure to require obstetrician review on admission with reduced fetal movement and delayed induction of labour View source Lack of clear guidance for managing a prolonged episode of reduced fetal movement View source Inconsistent and unclear diarising, prioritisation and management of induction of labour View source Failure to closely observe a concerning cardiotocograph View source Failure to review cardiotocography after induction of labour commenced View source Failure to advise return to triage for further monitoring during ongoing reduced fetal movement View source See 7 more concerns
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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.
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AI-generated summary
Xander Curran-Pass · 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
Xander Curran-Pass was delivered by category C Caesarean Section on 15 September 2018 after reduced fetal movement, delayed induction of labour, and concerning CTG findings. Resuscitation was unsuccessful and he died; post-mortem examination identified poor placental function associated with chronic villitis and thrombotic vasculopathy. The substantive concerns included delays in review and delivery, inadequate monitoring and documentation, and unclear or inconsistent processes for managing induction of labour and reduced fetal movement.
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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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on pethidine use with significant reduced fetal movement
Wider context from the report “6. Xander's mother was given pethidine. There was no guidance on issues to be considered in terms of advisability of pethidine where there was already significant reduced fetal movement ;
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Inconsistent fundal-height measurement and recording
Wider context from the report “5.Xander had his fundal height measured by tape measure by midwives in the community. There was a significant discrepancy between the recorded measurements of two different midwives , which altered where he was on the centile chart significantly ;
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of national provision for sharing maternity induction-of-labour learning
Wider context from the report “1.The inquest was told that there was a growing challenge to maternity units from the rise in Induction of Labour and the pressure to ensure that timescales set out in NICE guidance were met. In this case and since the death of Xander the trust have taken steps to reconfigure their IOL process to reduce risk but no provision to share such learning nationally existed ;
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Poor quality of admission documentation
Wider context from the report “7. The quality of documentation on admission was poor ;
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to require obstetrician review on admission with reduced fetal movement and delayed induction of labour
Wider context from the report “4. A review by an obstetrician did not take place on admission despite RFM and delayed IOL . The trust guidance did not require such a review . Such a review may have identified growing concern about condition of Xander;
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for managing a prolonged episode of reduced fetal movement
Wider context from the report “2.In the inquest reference was made to the guidance from the Royal College on reduced fetal movement. The guidance references individual episodes of RFM but does not give clear guidance on the approach to be taken where in effect there is one prolonged episode rather than multiple episodes of RFM ;
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Inconsistent and unclear diarising, prioritisation and management of induction of labour
Wider context from the report “8. The triage and IOL diary were poorly kept and used in different ways by staff . The trust has since changed the way records are kept to ensure consistency and improved its audit process. It is unclear if nationally there is clarity on the way in which IOLs are diarised, prioritised and managed ;
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to closely observe a concerning cardiotocograph
Wider context from the report “9. The CTG at 07.09 was concerning from the early stages but the evidence suggested that it was not closely observed ;
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to review cardiotocography after induction of labour commenced
Wider context from the report “10. The second CTG after IOL commenced was not reviewed .
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to advise return to triage for further monitoring during ongoing reduced fetal movement
Wider context from the report “3. Xander's mother was not told it would be advisable to return to triage for further monitoring in light of the ongoing reduced fetal movement. The inquest was told that this would have been advisable given the prolonged nature and the fact that it was unclear when she would be offered a slot for IOL;
” Open source report
7 Mar 2018 Venkata Naga Lakshyasi KAGGA · Prevention of Future Deaths report Manchester South
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Concerns raised 11 Lack of national reinforcement of paediatric assessment for young children View source Lack of understanding of button-battery risks among people responsible for small children View source Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service View source Failure to sustain and nationally reinforce the button-battery safety alert View source Failure to follow the policy for children under 5 View source Failure to complete or fully document child assessments View source Lack of POAU audit systems for detecting noncompliance View source Lack of understanding of the risks of subjective assessments in young children View source Failure to follow the POAU system View source Failure to value-check subjective assessments in young children View source Lack of child-resistant safety features for button batteries in commonly used household devices View source See 8 more concerns
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.
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AI-generated summary
Venkata Naga Lakshyasi KAGGA · 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
Venkata Naga Lakshyasi KAGGA died on 9 July 2017 after a button battery lodged in her oesophagus and caused an oesophageal arterial fistula. Before her death, she was seen by doctors and ambulance staff, but the battery was not identified. Concerns included failures to examine and assess her, non-compliance with ambulance policy for children under five, inadequate information sharing, and limited understanding of the risks posed by button batteries.
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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of national reinforcement of paediatric assessment for young children
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally.
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of button-battery risks among people responsible for small children
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service
Wider context from the report “7. The 111 service obtained detailed accounts of the history of illness. However systems for sharing information across the NHS are such that this information was not shared beyond the OOH GP service .
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to sustain and nationally reinforce the button-battery safety alert
Wider context from the report “2. NHS England issued a safety alert across the NHS in December 2014 relating to button batteries. During the inquest it was clear that the impact of that alert had lessened over time across the Trusts involved . The Trusts involved in the inquest had taken steps to highlight and reinforce the safety alert amongst their workforce but no such national work had taken place .
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the policy for children under 5
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally.
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or fully document child assessments
Wider context from the report “5. The importance of carrying out a full assessment of a child or documenting fully why it was not carried out on 6ᵗʰ July was not recognised by the medical staff involved .
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of POAU audit systems for detecting noncompliance
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system .
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the risks of subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata. The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the POAU system
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system.
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to value-check subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata . The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of child-resistant safety features for button batteries in commonly used household devices
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” Open source report
1 Mar 2018 George French Russell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to seek guidance during rapidly evolving labour situations View source Lack of structured and direct information sharing between hospital and ambulance services View source Lack of paramedic experience in managing footling breech deliveries View source Failure to provide or seek continuing expert support during footling breech deliveries View source See 1 more concern
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.
×
AI-generated summary
George French Russell · 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
George French Russell was born prematurely at 35 weeks and 1 day following a footling breech birth on 11 January 2017, in poor condition and with severe brain damage. He died on 23 January 2017 after being transferred for neonatal care. Concerns included inadequate information-sharing between services and a lack of sustained expert input during the breech delivery.
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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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to seek guidance during rapidly evolving labour situations
Wider context from the report “1. During the inquest it became clear that during the telephone conversation between EMAS and George’s mother her labour was rapidly developing. There was no evidence of the call taker seeking guidance on how to deal with a rapidly evolving situation other than to update the ambulance crew who were on route. (EMAS)
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of structured and direct information sharing between hospital and ambulance services
Wider context from the report “2. The way in which information was exchanged between Stepping Hill Hospital and EMAS meant that all those involved in making decisions were not in possession of key facts. There was no structure to how information was shared and it was passed 3rd hand .
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic experience in managing footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery . Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought.
” 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 Healthcare Safety Investigation Branch; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or seek continuing expert support during footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought .
” 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