24 Jun 2026 Nola-Reign Morgan · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 6 Delays in transferring patients between antenatal and HDU wards View source Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring View source Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring View source Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers View source Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected View source Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring View source See 3 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
Nola-Reign Morgan · 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
Nola-Reign Morgan was born prematurely on 5 February 2024 after her mother developed suspected chorioamnionitis, and died three days later despite resuscitation and neonatal care. The report identified delays in transferring her mother to the labour ward and high dependency unit, a period without fetal monitoring, and gaps in national and local guidance and staff training on monitoring and managing suspected chorioamnionitis in pre-term pregnancies.
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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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients between antenatal and HDU wards
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Insufficient training to enable obstetric and midwifery teams to identify the risk of chorioamnionitis and ensure adequate monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for identifying and treating chorioamnionitis in pre-term mothers
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of national antenatal guidance establishing when and in what circumstances fetal monitoring should be used, especially when chorioamnionitis is suspected
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure of local antenatal monitoring guidance to address chorioamnionitis, transfer times and consideration of continuous fetal monitoring
Wider context from the report “1. National Guidance. There is no national guidance in the antenatal setting to establish when and in what circumstances fetal monitoring should be used especially when chorioamnionitis is suspected. Further there is no specific guidance that has been brought to my attention to identify and treat chorioamnionitis in pre-term mothers. Clear guidance exists for intrapartum fetal monitoring but in this case the grey area between Nola-Reign's mother being nearly but not in active labour meant that there was confusion as to whether continuous monitoring should or could have been put in place.
2. Health Board Antenatal Fetal Monitoring Guidance. Following Nola-Reign’s death the serious incident review recommended new guidance to address antenatal fetal monitoring. However, the new local guidance for antenatal monitoring does not reference chorioamnionitis, transfer times or the need to consider continuous fetal monitoring.
3. Training. There is insufficient evidence from the Health Board of the nature or degree of training that has taken place since Nola-Reign’s death to assist obstetric and midwifery teams to identifying the risk of chorioamnionitis and to ensure adequate monitoring is in place in particular:
4. Delay in transferring between Antenatal and HDU wards. The delay in transferring Nola-Reign's mother from antenatal ward to HDU was over 1 hour in a situation when acuity was not raised. This issue was not identified by the Serious Incident Review yet was a material factor in the period when Nola-Reign's mother remained unmonitored and no steps have been taken to identify causes for delay and to avoid unnecessary delay occurring in the future.
” Open source report
11 Feb 2026 Chloe Angela Ulett · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure to routinely measure ammonia levels in adults presenting with behavioural change and confusion View source Lack of guidance on referral pathways for raised ammonia levels View source Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated View source Failure to consider ammonia testing nationally, causing risk of delayed diagnosis View source Short diagnostic and treatment window for metabolic disorders presenting with behavioural change and confusion View source Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors View source Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients View source Lack of awareness outside inherited metabolic disease teams of postpartum presentation of undiagnosed urea cycle disorders View source Failure to embed RCEM acute behavioural disturbance guidance in adult emergency medicine View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Chloe Angela Ulett · 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
Chloe Angela Ulett died at Birmingham Heartlands Hospital on 28 September 2024 from a previously undiagnosed urea cycle disorder that had been unmasked by giving birth. She developed confusion and excessive drowsiness after childbirth, was initially diagnosed with iron deficiency and discharged, and ammonia testing was delayed until several days later. The principal concerns were that early ammonia testing was not routine, relevant guidance was unclear and not embedded in adult medicine, and there remained a national risk of delayed diagnosis.
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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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely measure ammonia levels in adults presenting with behavioural change and confusion
Wider context from the report “2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients.
3. Nationally, early measurement of ammonia levels in adults presenting to the emergency department and other units for investigation and management of behavioural change and confusion are not routine practice .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on referral pathways for raised ammonia levels
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised . The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated . Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to consider ammonia testing nationally, causing risk of delayed diagnosis
Wider context from the report “9. It was further identified that inherited metabolic disease specialists are aware that a previously undiagnosed urea cycle disorders may be unmasked by giving birth and present for the first time in the post-partum period with symptoms of altered GCS including confusion, excessive drowsiness, seizures but this association is not known outside this speciality even in those caring for women in the post-partum period.
10. Following Miss Ulett's death the University Hospitals of Birmingham NHS Foundation Trust ('UHB') assessed the speciality teams who could encounter patients presenting with altered consciousness due to unmasked previous undiagnosed urea cycle disorder and identified the relevant specialities were emergency medicine, acute medical, intensive care medicine and maternity services.
11. Whilst UHB has done a lot of work internally with the specialities identified to raise awareness of the potential presentation of an unmasked previously undiagnosed urea cycle disorder to an emergency department with acute behavioural disturbance and the need for consideration of ammonia testing at an early stage, there remains a national risk from delay in diagnosis because ammonia testing has not been considered .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Short diagnostic and treatment window for metabolic disorders presenting with behavioural change and confusion
Wider context from the report “1. The window of opportunity to consider and make a diagnosis of a metabolic disorder and institute effective treatment is very short, 24 to 48 hours from the commencement of symptoms , and relies on early measurement of ammonia in an adult presenting with behavioural change and confusion .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department.
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1 , and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients
Wider context from the report “2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients .
3. Nationally, early measurement of ammonia levels in adults presenting to the emergency department and other units for investigation and management of behavioural change and confusion are not routine practice.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness outside inherited metabolic disease teams of postpartum presentation of undiagnosed urea cycle disorders
Wider context from the report “9. It was further identified that inherited metabolic disease specialists are aware that a previously undiagnosed urea cycle disorders may be unmasked by giving birth and present for the first time in the post-partum period with symptoms of altered GCS including confusion, excessive drowsiness, seizures but this association is not known outside this speciality even in those caring for women in the post-partum period .
10. Following Miss Ulett's death the University Hospitals of Birmingham NHS Foundation Trust ('UHB') assessed the speciality teams who could encounter patients presenting with altered consciousness due to unmasked previous undiagnosed urea cycle disorder and identified the relevant specialities were emergency medicine, acute medical, intensive care medicine and maternity services.
11. Whilst UHB has done a lot of work internally with the specialities identified to raise awareness of the potential presentation of an unmasked previously undiagnosed urea cycle disorder to an emergency department with acute behavioural disturbance and the need for consideration of ammonia testing at an early stage, there remains a national risk from delay in diagnosis because ammonia testing has not been considered.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to embed RCEM acute behavioural disturbance guidance in adult emergency medicine
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department .
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” 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 Remind midwives to recognise unexplained neurological or behavioural symptoms as clinical red flags and escalate them promptly.
Verbatim wording from the response “Learning from this case highlights the importance of maintaining a high index of suspicion when women present with unexplained neurological or behavioural symptoms. Midwives are reminded to treat such presentations as clinical red flags and to escalate concerns promptly using established local pathways.” Source location 2026-0086 - Response from Royal College of Midwives
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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 Matters in points 3–11 are outside the respondent’s role, so it will not comment further on them.
Verbatim wording from the response “Points 3-11 do not relate to the role of the RCM and therefore we feel unable to comment further.” Source location 2026-0086 - Response from Royal College of Midwives
Open published response
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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 NICE is responsible for developing national guidance on maternal assessment and associated adult medical assessment and treatment.
Verbatim wording from the response “Midwives are expected to practise in line with national guidance and local policies. In the absence of specific recommendations for ammonia testing, midwives would not routinely initiate such investigations without discussing clinical concerns with medical staff. NICE are responsible for development of national guidance to address maternal assessment or to link to associated guidance for adult medical assessment and treatment. The RCM would contribute professional expertise through consultation process as appropriate.” Source location 2026-0086 - Response from Royal College of Midwives
Open published response
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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 NHS England is responsible for reviewing local and regional protocols to consider ammonia testing for altered behaviour or confusion.
Verbatim wording from the response “Actions should include reinforcing education on the recognition of acute changes in mental status and their potential clinical significance. This should be delivered through mandatory training and regular clinical updates and strengthened through practice education across NHS England. Local and regional protocols should also be reviewed and updated to ensure consideration of ammonia testing when altered behaviour or confusion is identified, which is within the remit of NHS England.” Source location 2026-0086 - Response from Royal College of Midwives
Open published response
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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 Without specific ammonia-testing recommendations, midwives follow national guidance and local policies and do not routinely initiate testing without medical discussion.
Verbatim wording from the response “2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients.” Source location 2026-0086 - Response from Royal College of Midwives
Open published response
5 Nov 2025 Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 15 Lack of specialist commissioning of home birth services View source Failure to personalise and individualise pregnancy and birth risk assessment View source Failure to routinely provide women with community midwives’ delivery experience View source Unavailability or significant delay of required interventions during high-risk home births View source Lack of national data collection on home birth transfers, outcomes and out-of-guidance care View source Omission of maternal death risk from intrapartum guidance View source Inconsistent models of home birth care View source Failure to discuss maternal and neonatal death risk with women considering home birth View source Lack of national guidance on home birth care View source Lack of a national framework for safe home birth eligibility and midwifery practice View source Lack of mandated delivery experience requirements for midwives maintaining registration View source Lack of national guidance on staffing, training and experience for home birth midwives View source Use of pregnancy terminology that obscures stage-specific risk View source Lack of bespoke training needs analysis for home birth team midwives View source Lack of national guidance on the ethical responsibility and proportionality of offering home birth under the NHS View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jennifer Cahill and Agnes Cahill · 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
Jennifer Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.
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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist commissioning of home birth services
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service . There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to personalise and individualise pregnancy and birth risk assessment
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child. Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely provide women with community midwives’ delivery experience
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification. There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Unavailability or significant delay of required interventions during high-risk home births
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care. There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of national data collection on home birth transfers, outcomes and out-of-guidance care
Wider context from the report “9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Omission of maternal death risk from intrapartum guidance
Wider context from the report “5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby . There is no mention in the guidance of risk to the mother .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Inconsistent models of home birth care
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss maternal and neonatal death risk with women considering home birth
Wider context from the report “4. Even though there is a very small risk of death, this is not something which is discussed with women particularly in relation to maternal death , even if the woman has a recognised risk such as a post-partum haemorrhage. There is no guidance to ensure the risk of death to both mother and baby is discussed with any woman considering a home birth irrespective of being considered high or low 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on home birth care
Wider context from the report “1. There is no national guidance in respect of home births . Specifically, robust evidenced based guidance on home birth care , similar to that which is in place for intrapartum care in a hospital setting.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of a national framework for safe home birth eligibility and midwifery practice
Wider context from the report “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where required interventions cannot take place or would be significantly delayed and there is no robust framework for midwives supporting home birth care . There is no national guidance to support consistent practice across the country including, for example, details of clinical scenarios where women, following robust assessment, have been considered too high risk to safely receive care in a home-setting .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated delivery experience requirements for midwives maintaining registration
Wider context from the report “7. In order to maintain their skills, there is no set number of deliveries a community midwife must conduct following qualification . There is no mandated number of deliveries that any midwife (irrespective of the settings in which they are working) must complete once they have qualified as a midwife in order to maintain their registration. The level of experience of community midwives in conducting deliveries is not information routinely provided to women to inform their decision whether to have a homebirth.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on staffing, training and experience for home birth midwives
Wider context from the report “10. The no national guidance on the model of staffing, training and experience for midwives providing home birth care .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Use of pregnancy terminology that obscures stage-specific risk
Wider context from the report “6. Terminology around pregnancies describes them as ‘high’ or ‘low risk pregnancy’ and leads women to consider that pregnancy encompasses all stages through to delivery of a child . Practice does not personalise or individualise risk so women can fully understand what the level of risk is for them in actually being pregnant, or what the level of risk is for them in giving birth.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of bespoke training needs analysis for home birth team midwives
Wider context from the report “8. No bespoke training needs analysis has been conducted focusing on midwives practicing in home birth teams .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on the ethical responsibility and proportionality of offering home birth under the NHS
Wider context from the report “3. The lack of national guidance means there are differing models of care and unlike other specialities home births are not a specialist commissioned service. There is no national guidance considering the ethical responsibility and proportionality of offering a home birth model under the NHS framework .
” Open source report
×
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 Engage with NHS England, regulators and arm’s-length bodies to support development of a national standardised home birth policy.
Verbatim wording from the response “• The RCM has engaged actively with NHS England, regulators, and arm’s length bodies, including in the joint meeting on 8 December 2025, where the need for a national standardised policy on home birth services was formally recognised. NHS England has agreed to lead this work, with the RCM as a key stakeholder.” Source location Response from Royal College of Midwives
Open published response
×
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 Work with the Nursing and Midwifery Council through professional and policy channels on student learning, professional development and safe practice.
Verbatim wording from the response “• The RCM recognises that standards for education, registration, and revalidation fall within the remit of the Nursing and Midwifery Council (NMC). We continue to advocate for policies and commissioning arrangements that support midwives to maintain their competence and adhere to safe working standards that protect them from working long hours with inadequate rest periods. The RCM works in partnership with the NMC to highlight the implications of current service models for student learning, professional development, and safe practice, through appropriate professional and policy channels.” Source location Response from Royal College of Midwives
Open published response
×
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 Advocate for clear national frameworks supporting consistent, individualised communication of maternal and neonatal risks across maternity settings.
Verbatim wording from the response “• The RCM acknowledges that national consistency in discussing risk, including rare outcomes, requires system-level guidance. The RCM continues to advocate for clear national frameworks to support consistent, high-quality risk communication across all maternity settings, with dedicated funding and protected time for implementation.” Source location Response from Royal College of Midwives
Open published response
×
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 Promote professional learning through member communications and resources on risk escalation, informed consent and safe decision-making for complex births.
Verbatim wording from the response “• The RCM supports and promotes professional learning through member communications and resources, highlighting the importance of risk escalation and informed consent in line with existing RCM guidance such as Care Outside Guidance (2022) and Standing up for High Standards (2022) and the Nursing and Midwifery Council (2025) Principles for supporting women’s choices in maternity care.” Source location Response from Royal College of Midwives
Open published response
×
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 Advocate for protected, funded continuing professional development time and role-specific workforce development for home birth care.
Verbatim wording from the response “• The RCM has consistently highlighted the need for role-specific training and professional support in discussions with NHS partners. We advocate for protected, funded time for CPD. In line with other UK countries, such as Wales, the RCM calls on the government in England to ringfence hours of protected CPD annually for midwives, ensuring that all staff have sufficient opportunity to maintain skills and develop specialist expertise.” Source location Response from Royal College of Midwives
Open published response
×
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 Service-level implementation of maternity changes is outside the respondent’s authority and remit.
Verbatim wording from the response “The RCM is a professional association and trade union and does not hold statutory or operational responsibility for the delivery of maternity services. However, we play a key role in representing the professional voice of midwives, influencing policy, representing midwives and maternity support workers both individually and collectively in the workplace and working collaboratively with practice partners to advocate for safe, effective and high-quality maternity care. The response to this report is in the context of our responsibilities as a stakeholder within maternity services.” Source location Response from Royal College of Midwives
Open published response
×
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 NICE is responsible for redeveloping guidance to address maternal risk explicitly.
Verbatim wording from the response “5. NICE guidance on intrapartum care (2023 updated June 2025) Section 1.3.3 only refers to the potential risk of death to a baby. There is no mention in the guidance of risk to the mother.” Source location Response from Royal College of Midwives
Open published response
×
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 NHS England is responsible for leading national home-birth policy and ensuring providers implement it consistently.
Verbatim wording from the response “• The RCM has engaged actively with NHS England, regulators, and arm’s length bodies, including in the joint meeting on 8 December 2025, where the need for a national standardised policy on home birth services was formally recognised. NHS England has agreed to lead this work, with the RCM as a key stakeholder.” Source location Response from Royal College of Midwives
Open published response
×
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 NHS England and the Nursing and Midwifery Council are responsible for mandatory training and revalidation standards.
Verbatim wording from the response “• The RCM has consistently highlighted the need for role-specific training and professional support in discussions with NHS partners. We advocate for protected, funded time for CPD. In line with other UK countries, such as Wales, the RCM calls on the government in England to ringfence hours of protected CPD annually for midwives, ensuring that all staff have sufficient opportunity to maintain skills and develop specialist expertise.” Source location Response from Royal College of Midwives
Open published response
×
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 Ambulance provision and emergency-transfer accessibility protocols are outside the respondent’s remit.
Verbatim wording from the response “• Whilst not the remit of the RCM and the direct issue raised in the PFD Report, the provision of ambulance services and protocols to support accessibility of this service to women should they need an emergency transfer during labour and birth needs further consideration.” Source location Response from Royal College of Midwives
Open published response
×
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 The Nursing and Midwifery Council is responsible for education, registration and revalidation standards.
Verbatim wording from the response “competent practitioners. Without appropriate experience, future midwives may enter the workforce with insufficient exposure to home births, potentially undermining workforce capacity and safety.” Source location Response from Royal College of Midwives
Open published response
×
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 NHS England is responsible for national data collection and record keeping concerning home-birth outcomes and transfers.
Verbatim wording from the response “9. The lack of national data collection means there is no data to evidence the number of women who are transferred in during labour or after birth, maternal or neonatal outcomes, number of women who are considered out of guidance.” Source location Response from Royal College of Midwives
Open published response
15 Sep 2023 Eclipse Morrison · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 10 Failure to ensure appropriate timing and mode of delivery in high-risk pregnancies View source Unavailability of full Badgernet portal access View source Insufficient quality assurance of Badgernet entries View source Lack of clarity in interpreting Montgomery guidance and offering professional opinions on competing risks View source Insufficient technical knowledge and training for junior doctors and locums to identify serious risk factors View source Failure to ensure holistic review of relevant findings when planning timing and mode of birth View source Failure to test staff assimilation of maternity risk knowledge View source Unavailability of an implemented procedure for escalating inconclusive ultrasound measurements in high-risk pregnancies View source Failure to provide counselling supporting fully informed mode-of-delivery decisions where there is risk of shoulder dystocia View source Failure to follow existing maternity policies View source See 7 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.
×
AI-generated summary
Eclipse Morrison · 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
Eclipse Morrison died at Nottingham City Hospital on 21 July 2021, the day after her birth, following perinatal asphyxia and complications associated with gestational diabetes, excessive fetal growth and shoulder dystocia. The principal concerns included failures to follow up missed appointments, consider and discuss appropriate timing and mode of delivery, identify risk factors during labour, and ensure adequate fetal monitoring. Further concerns related to the implementation and quality assurance of Badgernet, escalation procedures for ultrasound concerns, counselling about shoulder dystocia, and interpretation of Montgomery guidance.
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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure appropriate timing and mode of delivery in high-risk pregnancies
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Unavailability of full Badgernet portal access
Wider context from the report “2. Access to Badgernet portal / full implementation of the Badgernet software
It seems that the Badgernet system is being relied on to address a number of issues which were identified in this case, and heavy reliance is being placed on a system which is not yet fully implemented . The concern remains that a critical aspect of this system, access to the portal, will not be in place until autumn 2023 at the earliest .
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Insufficient quality assurance of Badgernet entries
Wider context from the report “3. Quality Assessment
I am informed that Badgernet can easily identify fields which have not been completed and will prevent a record being closed until the field is completed, but it cannot identify the quality of any such entries . I am told that the quality checks are made on ten sets of notes per month out of an estimated 3,000 records that will be open at any one time. The concern remains that there is insufficient quality assurance in this 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in interpreting Montgomery guidance and offering professional opinions on competing risks
Wider context from the report “6. Interpretation of Montgomery
Ante-natal care is unique in that decisions have to be made for the benefit of two patients (the mother and the baby) and the treatment options for each may, as in this case have competing risks and benefits. In addition, in ante-natal care, the circumstances may change and action may need to be taken very quickly.
On the basis of evidence given at the inquest, there seems to be a lack of clarity as to the way in which Montgomery guidance are interpreted. It was acknowledged in evidence that parents often want a steer as to the best/safest course of action and that may require medical professionals to express opinions as to the weight to be placed on different risk factors. In some cases, parents may prefer to rely on the viewpoint of an experienced medical professional. It seems that medical professionals do not feel they can offer this assistance as it might be interpreted as trying to impose their opinion on the parent. The way in which Montgomery is interpreted and the extent to which medical professionals can offer an opinion is of wider concern than just the actions of those at GEH and should be considered by those who produce the guidance and deliver training to medical professionals.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Insufficient technical knowledge and training for junior doctors and locums to identify serious risk factors
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these , so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure holistic review of relevant findings when planning timing and mode of birth
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to test staff assimilation of maternity risk knowledge
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an implemented procedure for escalating inconclusive ultrasound measurements in high-risk pregnancies
Wider context from the report “4. Procedure for escalating concerns arising out of Ultrasound Scans (USS)
I understand that the procedure for escalating concerns arising out of a USS where it is not possible to obtain an accurate measurement in a high-risk pregnancy is currently under review . I am told that the new policy is not in place . The concern remains that no date has been set for its implementation.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to provide counselling supporting fully informed mode-of-delivery decisions where there is risk of shoulder dystocia
Wider context from the report “5. Counselling for mothers at increased risk of shoulder dystocia
I have not seen any indication that all mothers identified to have an increased chance of shoulder dystocia now receive counselling regarding the risks and benefits associated with vaginal birth or CS. Assisting mothers to understand the implications of risks they face is fundamental to supporting them to make fully informed decisions, in accordance with Montgomery. The concern remains that there is no clear plan in place to ensure mothers receive the support they require to make fully informed decisions in relation to mode of delivery where there is risk of shoulder dystocia.
” 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 Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Failure to follow existing maternity policies
Wider context from the report “1. Risk analysis / mode and timing of birth
A significant factor was the failure to consider an elective Caesarean Section (CS). It is not clear why on this history and consideration of mode of delivery did not include a consideration of an elective CS at any stage, by any of the doctors involved.
Evidence was given that existing policies in place at GEH were not followed and the reason for this failure has not been identified.
Whilst Badgernet could be a useful tool, the evidence suggested that it is being regarded as a first line of defence rather than a failsafe. I am told that the Badgernet maternity system implemented in October 2021 will resolve the problems relating to mode and timing of birth, in that the system will require a consultant to approve a decision for CS/induction of labour (IOL) and that IOL’s will not be approved by the labour coordinator unless the paper booking has been approved on paper. However, on the evidence received it is not clear how this will assist if the risk factors and the need to consider IOL/elective CS have not been identified, by junior staff, thus triggering the need for escalation to/approval by a consultant.
I am not clear what has been done to ensure that junior doctors and locums have sufficient technical knowledge to ensure that they are able to identify serious risk factors and alert the consultant to these, so that the consultant may consider the appropriate mode of delivery. No information was provided as to the availability of regular face to face training for all grades concerning high-risk pregnancies not just for career trainees and foundation doctors.
I am told that a memo was sent to all junior doctors reminding them that any plan for either IOL or elective CS must be approved by a consultant and that an induction pack containing that information is provided to new starters and locums.
I have seen the Women’s and Children Clinical Education Guideline introduced in November 2022. I am told that the information was placed in a prominent position on notice boards, staff rooms and in blogs.
It is not clear how the assimilation of this knowledge is tested. It was suggested that this may be in appraisal, but this seems only likely to identify problems after they arise. In any event it seems these methods of dissemination of information and the appraisal system were in place at the time of Eclipse’s birth but did not ensure that the doctors involved in her mother’s care appreciated the impact of the risk factors in this pregnancy.
It was not explained how Badgernet or any policy or procedure in place, would ensure that there is a holistic review (including ultrasound scan findings) when planning for timing and mode of birth.
The concern remains that there will be further failure to ensure that appropriate timing and mode of delivery will be provided in high-risk pregnancies.
” Open source report
Concerns raised 1 Lack of national guidance on feeding expectations for low-risk formula-fed babies in the first 72 hours 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.
×
AI-generated summary
Muhammad Zayaan ul Hasan · 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
Muhammad Zayaan ul Hasan was born on 18 November 2020 and died at home on 21 November 2020, aged three days, after developing poor feeding, sleepiness and abnormal breathing. The principal concern was a lack of national guidance on feeding expectations for low-risk formula-fed babies during the first 72 hours, which may contribute to premature discharge and inadequate information for families about warning signs.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on feeding expectations for low-risk formula-fed babies in the first 72 hours
Wider context from the report “The MATTER OF CONCERN is that there is a lack of national guidance on feeding expectation for a formula fed baby in the first 72 hours when the baby is considered to be low risk . This may lead to babies being prematurely discharged and to families not being provided with appropriate information on signs of concern.
” Open source report
22 Feb 2017 Maxim Karpovich · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1 Lack of competence in intrapartum CTG interpretation View source
Responses linked to these concerns
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AI-generated summary
Maxim Karpovich · 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
Baby Maxim Karpovich was delivered by emergency caesarean section on 16 March 2015 with no signs of life, was resuscitated and treated in the Neonatal Intensive Care Unit, and died later that day. The concerns included failures to recognise and correctly interpret abnormal cardiotocograph traces, together with wider concerns about the adequacy of CTG interpretation training and competency assessment for midwives and obstetricians.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Midwives; that does not assign responsibility.
PFD Monitor interpretation Lack of competence in intrapartum CTG interpretation
Wider context from the report “(1) It was apparent that the Midwives involved with Maxim’s birth and a Junior Obstetrician, appeared not to understand that the cardiotocograph (CTG) trace was abnormal on several occasions . The Obstetric Registrar, at 2357 hours, incorrectly classified the CTG to be normal when it clearly was not . The baby, Maxim, who was delivered by an emergency caesarean section. Expert evidence stated that if the caesarean section had been carried out by midnight, the baby would have survived, although there could have been some neurological deficit.
(2) This Inquest and many others previously, have caused me to note that Midwives and Obstetricians lack the core skills to interpret CTG tracings for intrapartum care .
” 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 Develop and provide the eFM web-based resource to improve electronic fetal monitoring interpretation and subsequent management.
Verbatim wording from the response “The RCM in partnership with the Royal College of Obstetricians and Gynaecologists and Health Education England e-Learning for Healthcare developed a comprehensive web-based resource called eFM: an e-learning resource aimed at improving the interpretation of electronic fetal monitoring and subsequent management. This is a free resource for all employees of the National Health Service and contains knowledge-based interactive tutorials, assessments and case studies.” Source location Response-from-Royal-College-of-Midwives
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations