16 Sep 2025 Mohammed Ismail KHAN · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Lack of mandatory and comprehensive paramedic training in obstetric emergencies View source Failure to adhere to clinical guidance for assessing and managing delayed breech birth View source
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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
Mohammed Ismail KHAN · 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
Mohammed Ismail Khan sustained a catastrophic brain injury during a breech delivery at 35 weeks and 2 days gestation on 6 September 2022, after his mother had been discharged from hospital earlier that day despite antenatal risk factors. He later died following a respiratory infection, with the medical cause of death recorded as respiratory failure due to parainfluenza virus infection, with hypoxic-ischaemic brain damage. The investigation identified delayed and suboptimal emergency care, failure to adhere to breech-delivery guidance, and the absence of mandatory paramedic training in obstetric emergencies as substantive concerns.
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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 NHS Herefordshire and Worcestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory and comprehensive paramedic training in obstetric emergencies
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted.
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development .
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course .
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk .
” 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 NHS Herefordshire and Worcestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to clinical guidance for assessing and managing delayed breech birth
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted .
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development.
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course.
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk.
” Open source report
20 Dec 2022 Carl Robert ELLSON · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 3 Lack of a clear and safe system for GPs to contact mental health teams for urgent reviews View source Failure to arrange mental health practitioner contact without placing the burden on patients in crisis View source Lack of GP awareness of how to request urgent psychiatric reviews View source
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AI-generated summary
Carl Robert ELLSON · 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
Carl Robert ELLSON was found deceased in a wooded area on 16 July 2022 after sustaining a fatal self-inflicted wound. He had been experiencing anxiety and insomnia and had presented with suicidal ideation shortly before his death. The concerns identified were that GP access to urgent mental health reviews was unclear and unsafe, that patients in crisis were expected to initiate contact with mental health practitioners, and that GPs were not fully aware of how to request an urgent psychiatric review.
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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 NHS Herefordshire and Worcestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear and safe system for GPs to contact mental health teams for urgent reviews
Wider context from the report “1. On 13/07/22 Dr Ellson's GP needed to arrange an urgent mental health review as Dr Ellson had presented with suicidal ideation. The GP had significant difficulties trying to contact the Mental health team with messages giving incorrect numbers. My concern is that the system for GPs to contact mental health teams for urgent reviews is not clear nor safe.
” 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 NHS Herefordshire and Worcestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange mental health practitioner contact without placing the burden on patients in crisis
Wider context from the report “2. Once contact had been made and a request was made for Dr Ellson to be assessed by the mental health team, the system in place is for the patient to call the mental health practitioner. My concern is that the patient is likely to be in crisis, which is why a referral is being made, and the burden should not be put on them to make the call.
” 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 NHS Herefordshire and Worcestershire Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of GP awareness of how to request urgent psychiatric reviews
Wider context from the report “3. The GP caring for Dr Ellson on 13/07/22 was unaware that she could make a request for a psychiatric review of the patient. The inquest heard how this was not well known by local GPs. My concern is that GPs should be fully aware how to request an urgent psychiatric review for patients.
” 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 Refresh Teamnet referral information to ensure it is relevant and prominent.
Verbatim wording from the response “same numbers available to the public. Both email address and contact telephone number are prominent on the GP Referral Form. Whilst we believe GPs are aware of the correct numbers, going forward, we will continue to issue reminders to all GP surgeries of the contact numbers through Teamnet, which is the service used for all referral and service information. Between our two organisations we are refreshing all of the information on Teamnet, to ensure that the information is both relevant and prominent.” Source location Response from NHS Herefordshire and Worcestershire
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate information to GPs about urgent psychiatric review routes through direct communications, Teamnet and primary care network meetings.
Verbatim wording from the response “The Trust’s investigation did identify that the GP in this case would have liked to refer directly to a psychiatrist. We understood that they were reassured that the Trust follows the national model. Within our process the patient can see a consultant psychiatrist if they were taken on by the Home Treatment Team, as medical reviews are an integral part of how that team operates. The action from the investigation was therefore to ensure that local GPs were supported and provided with this information going forward. Again, this was achieved by sending all GPs direct communications with a reminder of this information on 31st December 2022. In addition, we have ensured that the relevant information is on Teamnet and also regularly discussed in the local primary care network meetings between GPs and their local mental health teams.” Source location Response from NHS Herefordshire and Worcestershire
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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 issuing all GP surgeries reminders of mental health referral contact numbers through Teamnet.
Verbatim wording from the response “same numbers available to the public. Both email address and contact telephone number are prominent on the GP Referral Form. Whilst we believe GPs are aware of the correct numbers, going forward, we will continue to issue reminders to all GP surgeries of the contact numbers through Teamnet, which is the service used for all referral and service information. Between our two organisations we are refreshing all of the information on Teamnet, to ensure that the information is both relevant and prominent.” Source location Response from NHS Herefordshire and Worcestershire
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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 Use the Medical Leadership Forum to reiterate the urgent referral process and address concerns.
Verbatim wording from the response “As part of striving for continuous improvement our Medical Leadership Forum (which includes the ICB, Trust and General Practice) will also take this issue forward, to reiterate the process and ensure any concerns are addressed.” Source location Response from NHS Herefordshire and Worcestershire
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The established urgent-access process, including Single Point of Access, Home Treatment, Crisis Team and out-of-hours arrangements, is considered sufficient.
Verbatim wording from the response “The Trust’s current process for enabling urgent access to mental health services is longstanding and we thought well recognised. GPs can contact the Single Point of Access (SPA) who pass the referral on to the relevant/local Home Treatment Team (HTT) who then triage the referral and either allocate themselves or the Crisis Team dependent on risk and clinical presentation. If a call comes through out of hours, it goes straight to the Crisis team which is a 24/7 service.” Source location Response from NHS Herefordshire and Worcestershire
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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 Patients in crisis are not expected to initiate contact; Home Treatment or Crisis Teams contact patients after referral and triage.
Verbatim wording from the response “We would like to reassure you that a process is in place which does not burden the patient with the responsibility of making a call to initiate engagement with services when in a crisis. In this instance, the patient in this case was not asked by the Home Treatment Team or the Crisis Team to call them at any point. Further, it is never the usual process for a patient to contact Home Treatment following a referral from a GP. The call takers from both the Home Treatment Team and the Crisis Team, who took the call from the SPA on the day in question both state they did not ask the GP to tell the patient to call either team. This is supported by the contemporaneous recording following the conversations.” Source location Response from NHS Herefordshire and Worcestershire
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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 Home Treatment or Crisis clinicians, rather than GPs, determine and arrange urgent psychiatric medical review following assessment.
Verbatim wording from the response “The Trust follows a national model which allows GPs to refer for an urgent psychiatric assessment in terms of a psycho-social assessment by a Home Treatment or Crisis Clinician, and within that they can provide an opinion that they believe a medical review from a psychiatrist is required. However, the gatekeeping for this, as well as the responsibility to arrange it, falls on the Home Treatment and/or Crisis Clinician completing the subsequent assessment. GPs can also refer to the Neighbourhood Mental Health Team for a review from a psychiatrist although this route is not intended for urgent referrals.” Source location Response from NHS Herefordshire and Worcestershire
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations