28 May 2019 Maia Hazel Ann Strachan · Prevention of Future Deaths report Newcastle upon Tyne
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Concerns raised 6 Failure to use Foetal Scalp Electrodes for critical fetal distress information View source Suboptimal clinical documentation View source Lack of patient-specific sequential scan data storage and sonographer alerts View source Failure to provide advice and explanations for informed pregnancy and delivery decisions View source Failure to circulate independent expert findings and conclusions to relevant maternity staff View source Unavailability of clinician access to obstetric and diabetic records View source See 3 more concerns
Responses linked to these concerns
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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
Maia Hazel Ann Strachan · 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
Maia Hazel Ann Strachan was born on 6 July 2017 and died in hospital on 7 July 2017 after a complicated delivery involving shoulder dystocia, hypoxic ischaemic encephalopathy and severe macrosomia. The report identified concerns about inaccurate and suboptimal ultrasound assessment, inaccessible obstetric and diabetic records, missed opportunities for Caesarean delivery and joint decision-making, fetal scalp electrode use, documentation, and dissemination of expert findings.
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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 North Tyneside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use Foetal Scalp Electrodes for critical fetal distress information
Wider context from the report “(4) Foetal Scalp Electrode:
The use of Foetal Scalp Electrodes (FSE) provide critical information in respect of foetal distress and the time implications thereof .
The Trust should draft and implement a clear and comprehensive Local Policy/Protocol for FSE use.
” 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 North Tyneside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Suboptimal clinical documentation
Wider context from the report “(5) Suboptimal Documentation :
The Trust should implement a robust training and audit plan to address the risks of this occurring in the future.
” 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 North Tyneside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of patient-specific sequential scan data storage and sonographer alerts
Wider context from the report “(1) The ability to store sequential scan data specific to each patient and provide alerts to the Sonographer .
This would facilitate comparison and prompt further investigation potentially altering a patient’s care plan and outcome.
The Trust’s plan to procure software to facilitate the above should be urgently implemented.
” 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 North Tyneside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide advice and explanations for informed pregnancy and delivery decisions
Wider context from the report “(3) Joint Decision Making: -
Provision of advice and explanation of the risks of pregnancy and the risks/benefits of vaginal delivery or by Caesarean Section are essential to ensure informed decision making .
The Trust should draft and implement a clear and comprehensive Local Joint Decision Making Policy/Protocol.
” 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 North Tyneside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to circulate independent expert findings and conclusions to relevant maternity staff
Wider context from the report “(6) The Findings and Conclusions of ████████ (Independent Expert Witness):
A redacted copy of ████████ report and conclusions should be circulated to all obstetrics and gynaecology staff (both nursing and medical) and all midwives .
” 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 North Tyneside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of clinician access to obstetric and diabetic records
Wider context from the report “(2) A system of joint obstetric and diabetic care operates without the facility for clinicians to access patients’ obstetric and diabetic records whether manually or electronically .
Accessibility is essential to inform clinical decisions and should be urgently addressed
” Open source report
9 Oct 2015 Patrick Joseph Carrick · Prevention of Future Deaths report Newcastle upon Tyne
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Concerns raised 3 Failure to follow or explain departures from a patient's management plan View source Failure to action crucial blood analysis results View source Inadequate completion of nursing and medical notes View source
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
Patrick Joseph Carrick · 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
Patrick Joseph Carrick underwent laparoscopic high anterior resection for colorectal cancer on 23 January 2012 and subsequently deteriorated, later dying from a rare but recognised complication of the surgery. Concerns included a significant unexplained departure from his management plan during rapid deterioration, failure to action blood analysis results, inadequate monitoring, delays in administering antibiotics, and inadequate completion of nursing and medical notes.
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 North Tyneside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to follow or explain departures from a patient's management plan
Wider context from the report “(1) There was a significant departure from a patients management plan without explanation
(2) The above was compounded as it occurred in a period of rapid deterioration
(3) Crucial blood analysis results were not actioned
(4) Inadequate completion of nursing and medical notes
” 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 North Tyneside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to action crucial blood analysis results
Wider context from the report “(1) There was a significant departure from a patients management plan without explanation
(2) The above was compounded as it occurred in a period of rapid deterioration
(3) Crucial blood analysis results were not actioned
(4) Inadequate completion of nursing and medical notes
” 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 North Tyneside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate completion of nursing and medical notes
Wider context from the report “(1) There was a significant departure from a patients management plan without explanation
(2) The above was compounded as it occurred in a period of rapid deterioration
(3) Crucial blood analysis results were not actioned
(4) Inadequate completion of nursing and medical notes
” 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