Royal College of Nursing and Midwifery (source wording)

Health and care · Professional body

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First report 9 Oct 2020•Latest report 9 Oct 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 Royal College of Nursing and Midwifery (source wording) linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Nottinghamshire

    AI-generated summary

    Noah Richard Poole · 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

    Noah Richard Poole died aged 8 days from complications of a head injury sustained during difficult extraction at his caesarean delivery. The report identified failures to counsel his mother properly about delivery options and to agree a birth plan, as well as a lack of professional guidance and training concerning vaginal pushes and fetal pillows during difficult fetal extraction.

    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 Nursing and Midwifery (source wording); that does not assign responsibility.

    PFD Monitor interpretation

    Lack of professional guidance for vaginal pushes in theatre

    Wider context from the report

    “(1) Lack of professional Guidance regarding the use of a vaginal push to disimpact the fetal head Almost all of the Midwives in this case told me that they had been asked perform a ‘vaginal push’ in theatre at some point in their career, but it is not something that frequently occurs, nor is it something they are trained to do. Furthermore, practice varies between doctors as to whether they ask a fellow doctor to provide the vaginal push, or a midwife, and whether they provide the individual with any guidance on exactly what they should do. The Midwife did exactly what was asked of her to “push” Noah’s head. She performed this in the usual way that midwives perform a vaginal examination, that is, with two pointed digits. I have been unable to determine whether it was the Doctor’s fingers or the Midwife’s fingers that caused the depressed fracture to Noah’s head, but both are a possibility, and the issue remains that midwives are asked to perform a manoeuvre in a theatre environment for which they have received no training nor is there any professional guidance. Equally, there is no guidance for the Doctor as to whether and what information they ought to impart to the midwife before they embark on the procedure. ”
    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 Nursing and Midwifery (source wording); that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training for midwives performing vaginal pushes in theatre

    Wider context from the report

    “(1) Lack of professional Guidance regarding the use of a vaginal push to disimpact the fetal head Almost all of the Midwives in this case told me that they had been asked perform a ‘vaginal push’ in theatre at some point in their career, but it is not something that frequently occurs, nor is it something they are trained to do. Furthermore, practice varies between doctors as to whether they ask a fellow doctor to provide the vaginal push, or a midwife, and whether they provide the individual with any guidance on exactly what they should do. The Midwife did exactly what was asked of her to “push” Noah’s head. She performed this in the usual way that midwives perform a vaginal examination, that is, with two pointed digits. I have been unable to determine whether it was the Doctor’s fingers or the Midwife’s fingers that caused the depressed fracture to Noah’s head, but both are a possibility, and the issue remains that midwives are asked to perform a manoeuvre in a theatre environment for which they have received no training nor is there any professional guidance. Equally, there is no guidance for the Doctor as to whether and what information they ought to impart to the midwife before they embark on the procedure. ”
    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 Nursing and Midwifery (source wording); that does not assign responsibility.

    PFD Monitor interpretation

    Lack of professional guidance for the use of fetal pillows

    Wider context from the report

    “(2) Lack of Professional Guidance in relation to the use of fetal pillows The inquest further discovered that the understanding on the use of fetal pillows in this scenario is inconsistent. The manufacturers appear to suggest that the mother’s cervix should be at least 8cm dilated, but again, practice and understanding seems to vary. I made enquiries of the Health Sector Investigation Branch. They were not aware of any national guidance either on vaginal pushes in theatre or the use of fetal pillows. Nor could I find any guidance on the RCNM website. The Trust has made enquiries of the RCOG and other Trusts, but again there appears to be an absence of guidance and variation of practice across the Country. While I accept the incidence of traumatic head injury as a result of difficult fetal extraction is, thankfully, rare, and that midwives are only asked to provide a vaginal push ‘in extremis’, any procedure should be performed by a competent and capable individual who has the support of robust professional guidance to assist them. All witnesses in this case said it would be useful to have multidisciplinary guidance and training on this issue. ”
    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