Rhsbsw LLP

Private and voluntary organisations · Limited liability partnership

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First report 16 Jul 2020•Latest report 16 Jul 2020

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Addressed to “RADCLIFFESLEBRASSEUR LLP”, a former name of Rhsbsw LLP.

    Norfolk

    AI-generated summary

    Kobi David WRIGHT · 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

    Kobi David WRIGHT was delivered on 3 March 2019 after unsuccessful forceps and caesarean delivery attempts and was declared dead after showing no signs of life. The concerns included conflicting accounts of cervical dilatation and the clinical reasoning for proceeding to delivery, failure to allow further progression before intervention, aspects of the forceps and caesarean procedures, and a lack of recent emergency obstetric 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 Rhsbsw LLP; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to carry out a further vaginal examination after an hour before deciding how to proceed with delivery

    Wider context from the report

    “5. Dr ████████ gave evidence that his arranging to take Kobi’s mother to theatre and prepare for delivery, and then carrying out a further vaginal examination at that time, would stand in for a later examination to see how matters were progressing. This was not regarded as good practice by the expert on the basis, it would be better to carry out a further examination after an hour, and then decide how to proceed with the delivery. ”
    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 Rhsbsw LLP; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of recent emergency obstetrics training

    Wider context from the report

    “12. There was no evidence that Dr ████████ had undergone training in emergency obstetrics in the recent period prior 3 March 2019. Dr ████████ has undergone training since 3 March 2019 but at the instigation of North Devon District Hospital. ”
    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 Rhsbsw LLP; that does not assign responsibility.

    PFD Monitor interpretation

    Rotation of the baby’s head alone during obstructed delivery

    Wider context from the report

    “7. Dr ████████ proceeded with a forceps delivery of the baby’s head. The body did not follow and the cervix “retracted” (which Dr ████████ had not encountered before. Nor had Mr ████████ the expert witness). Dr ████████ cut the cervix and rotated the head and tried unsuccessfully to deliver the shoulders through the incision. Mr ████████ expert said in evidence the baby’s head on its own should never be rotated due to the damage this can cause. ”
    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 Rhsbsw LLP; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to appropriately interpret CTG readings and the full clinical picture before proceeding to delivery

    Wider context from the report

    “4. Further ████████ second statement 21.4.2020, refers to some consideration being given to variable decelerations and variabilities contained in the CTG trace when making his decision to proceed to delivery at that time. It was accepted by Dr ████████ Ms ████████ consultant and Mr ████████ expert, that the CTG readings were within normal range and would not be a reason to proceed to delivery at that time. Their evidence was it would be appropriate in light of the full clinical picture and the CTG readings to “wait and see” how matters progressed. ”
    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 Rhsbsw LLP; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accept consultant assistance during the procedure

    Wider context from the report

    “6. Dr ████████ did not accept the Consultant’s offer of assistance but regarded himself as fully competent to carry out the procedure. ”
    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

Data last updated 7 September 2026