Musgrove Park Hospital

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First report 5 Aug 2025•Latest report 5 Aug 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Musgrove Park Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

5 Aug2025
Devon, Plymouth and Torbay
Concerns raised8
1. Lack of training to recognise unusual foetal movements or compromise
2. Lack of midwives’ familiarity with processes and policies for understanding foetal compromise
3. Lack of policies for rapid escalation of emergency events
1. Absence of a culture of appropriate professional challenge
2. Lack of training on rapid escalation of emergency events
3. Lack of adequate communication between healthcare professionals on the maternity unit
4. Lack of understanding and implementation of policies for additional staffing during high acuity or emergency situations
5. Gap in policy for in-person attendance by consultants or midwives when understaffing may compromise patient safety
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Daisy May McCoy · 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

Daisy May McCoy was born by Caesarean section on 9 February 2022 after reduced and unusual foetal movement was reported, and died in a children’s hospice on 22 February 2022 following a brain injury and peri-natal asphyxia. The report identified concerns about recognising foetal compromise, communication and escalation between staff, staffing and consultant attendance, professional challenge, and the adequacy and implementation of relevant policies and training.

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 Musgrove Park Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of training to recognise unusual foetal movements or compromise
Wider context from the report
“1. A lack of training to recognise unusual foetal movements / compromise and implementation of such training. ”
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 Musgrove Park Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of midwives’ familiarity with processes and policies for understanding foetal compromise
Wider context from the report
“2. A lack of familiarity with the processes and polices by midwives to understand foetal compromise. ”
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 Musgrove Park Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of policies for rapid escalation of emergency events
Wider context from the report
“3. A lack of training and policies on rapid escalation of emergency events ”
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 Musgrove Park Hospital; that does not assign responsibility.
PFD Monitor interpretation
Absence of a culture of appropriate professional challenge
Wider context from the report
“6. No culture of appropriate professional challenge. ”
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 Musgrove Park Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of training on rapid escalation of emergency events
Wider context from the report
“3. A lack of training and policies on rapid escalation of emergency events ”
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 Musgrove Park Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of adequate communication between healthcare professionals on the maternity unit
Wider context from the report
“7. A lack of adequate communication between different health care professionals on the maternity unit. ”
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 Musgrove Park Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of understanding and implementation of policies for additional staffing during high acuity or emergency situations
Wider context from the report
“5. A lack of understanding and implementation of the polices that additional staffing in times of high acuity or other emergency situations which if left unaddressed may leave patient safety compromised. ”
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 Musgrove Park Hospital; that does not assign responsibility.
PFD Monitor interpretation
Gap in policy for in-person attendance by consultants or midwives when understaffing may compromise patient safety
Wider context from the report
“4. A gap in policy to provide for both Consultants and or midwives to attend in person where understaffing may lead to patient safety being compromised outside of the recognised situations where this is required under the FIGO guidelines. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised8

Lack of training to recognise unusual foetal movements or compromise

Lack of midwives’ familiarity with processes and policies for understanding foetal compromise

Lack of policies for rapid escalation of emergency events

Absence of a culture of appropriate professional challenge

Lack of training on rapid escalation of emergency events

Lack of adequate communication between healthcare professionals on the maternity unit

Lack of understanding and implementation of policies for additional staffing during high acuity or emergency situations

Gap in policy for in-person attendance by consultants or midwives when understaffing may compromise patient safety