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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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.
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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Commission an article on metabolic conditions in the peripartum period for dissemination through The Obstetrician and Gynaecologist Journal.
Verbatim wording from the response “In response to the concern that there may be a lack of awareness of urea cycle disorders amongst obstetricians, the RCOG has commissioned an article covering ‘Metabolic Conditions in the Peripartum Period’, to be published in The Obstetrician and Gynaecologist Journal (TOG). This journal is widely read by members, fellows and trainees in obstetrics and gynaecology, and as such, is an effective way of disseminating this clinical information.” Source location 2026-0086 Response from Royal College of Obstetricians and Gynaecologists
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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Develop a Good Practice Paper on supporting women requesting care outside guidance, including obstetricians’ roles within the wider team.
Verbatim wording from the response “2. There is an increase in the number of women with ‘high risk pregnancies’ requesting home births where known 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.” Source location Response from Royal College of Obstetricians & Gynaecologists
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 Support obstetricians to provide women with information enabling informed choices about care during pregnancy, birth and the postnatal period.
Verbatim wording from the response “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.” Source location Response from Royal College of Obstetricians & Gynaecologists
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 Support NICE’s ongoing work to develop evidence-based guidance covering maternity care, including home-birth-relevant aspects.
Verbatim wording from the response “in an obstetric led unit. This guideline covers the general principles of care for women in all birth settings. The guideline provides advice regarding fetal monitoring in labour which is relevant to birth at home as well as in hospital settings, and links to the NICE Guideline on fetal monitoring in labour (2022)². The guideline also provides advice on care of the perineum to minimise the chance of perineal trauma as well as advice on the management of the third stage of labour (including “active management” of the third stage), initial assessment and management of post-partum haemorrhage and when to consider transfer to obstetric care) which is relevant to birth in any setting. Lastly the guideline covers resuscitation of the newborn including the training required for healthcare professionals, the need for emergency referral pathways and facilities for transfer.” Source location Response from Royal College of Obstetricians & Gynaecologists
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 best positioned to address the absence of guidance on maternal death risk in intrapartum care guidance.
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 Obstetricians & Gynaecologists
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 NHSE and DHSC are best positioned to address the lack of national data on home birth transfers, outcomes and care outside guidance.
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 Obstetricians & Gynaecologists
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 The RCM and NMC are best positioned to address national guidance on staffing, training and experience for midwives providing home birth care.
Verbatim wording from the response “10. There is no national guidance on the model of staffing, training and experience for midwives providing home birth care.” Source location Response from Royal College of Obstetricians & Gynaecologists
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 RCM and NMC are best positioned to address training needs analysis for midwives practising in home birth teams.
Verbatim wording from the response “8. No bespoke training needs analysis has been conducted focusing on midwives practising in home birth teams.” Source location Response from Royal College of Obstetricians & Gynaecologists
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 NHSE and DHSC are best positioned to address the ethical responsibility and proportionality of offering home birth within the NHS framework.
Verbatim wording from the response “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.” Source location Response from Royal College of Obstetricians & Gynaecologists
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 RCM and NMC are best positioned to address midwives’ delivery experience requirements and related information for women choosing home birth.
Verbatim wording from the response “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.” Source location Response from Royal College of Obstetricians & Gynaecologists
Open published response
27 Oct 2025 Louisa Walker · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 3 Increasing prevalence of impacted fetal head at caesarean section View source Absence of relevant training for impacted fetal head at caesarean section View source Lack of consistent guidance for managing impacted fetal head at caesarean section View source
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
Louisa Walker · 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
Louisa Walker was born on 25 May 2024 and died on 28 June 2024 after her head became impacted in her mother’s pelvis during a caesarean section. She suffered skull fractures and intracranial bleeding during attempts to disimpact her head. The principal concerns were the absence of national guidance for impacted fetal head at caesarean section, uncertainty and potentially inadequate training, and the increasing frequency of this emergency.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Increasing prevalence of impacted fetal head at caesarean section
Wider context from the report “3. I understand that impacted fetal head is becoming increasingly common .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Absence of relevant training for impacted fetal head at caesarean section
Wider context from the report “2. Whilst the algorithm referred to in RCOG scientific impact paper number 73 may well have been adopted by many trusts, there is a risk of uncertainty and absence of relevant training in respect of this obstetric emergency .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent guidance for managing impacted fetal head at caesarean section
Wider context from the report “1. There is no national guidance (by way of green top guideline or otherwise) dealing with impacted fetal head seen at caesarean section.
2. Whilst the algorithm referred to in RCOG scientific impact paper number 73 may well have been adopted by many trusts, there is a risk of uncertainty and absence of relevant training in respect of this obstetric emergency.
” 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 Consider developing a formal guideline when the evidence base permits.
Verbatim wording from the response “Scientific Impact Papers (SIPs) are used where the evidence base is still evolving and insufficient to support a formal Green-top Guideline. While Green-top Guidelines aim to provide clinical instructions, SIPs give expert analysis on the new scientific findings and highlight the future implications on practice. Although a SIP does not carry the status of a Green-top Guideline, it is a formal, peer-reviewed RCOG publication intended to inform national standards and practice.” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
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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 Produce and publish the second edition of Scientific Impact Paper No. 73 on managing impacted fetal head at caesarean birth.
Verbatim wording from the response “RCOG Scientific Impact Paper No. 73, Management of Impacted Fetal Head at Caesarean Birth (2025 Second Edition), was produced as part of the ABC programme. It provides a working definition of impacted fetal head, reviews the current evidence regarding prediction, prevention and management, and describes the recognised techniques for managing the emergency.” Source location Response from Royal College of Obstetricians and Gynaecologists
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 Continue reviewing emerging evidence on impacted fetal head at caesarean birth.
Verbatim wording from the response “The 2025 second edition was developed to reflect current evidence and clarify its strengths and limitations. We will continue to review emerging evidence and consider guideline development when the evidence base permits.” Source location Response from Royal College of Obstetricians and Gynaecologists
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 evidence base is insufficient to support a formal Green-top Guideline on impacted fetal head; guideline development will be considered when evidence permits.
Verbatim wording from the response “Scientific Impact Papers (SIPs) are used where the evidence base is still evolving and insufficient to support a formal Green-top Guideline. While Green-top Guidelines aim to provide clinical instructions, SIPs give expert analysis on the new scientific findings and highlight the future implications on practice. Although a SIP does not carry the status of a Green-top Guideline, it is a formal, peer-reviewed RCOG publication intended to inform national standards and practice.” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
Concerns raised 1 Failure of VBAC information to identify that uterine rupture can be fatal View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mabel Olivia Williams · 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
Mabel Olivia Williams suffered a fatal hypoxic injury during a trial of vaginal birth after caesarean section and died six days later in a neonatal intensive care unit in Bristol. The report identified concerns that information about VBAC did not explain that uterine rupture could be fatal, and that indicators of Mabel’s distress and her mother’s worsening condition were not recognised or conveyed in time to expedite her birth safely.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure of VBAC information to identify that uterine rupture can be fatal
Wider context from the report “When ████████ was advised about VBAC she was referred to internal guidance from the hospital and to the RCOG’s information leaflet “Birth options after previous caesarean section” (published in July 2016). I reviewed the information leaflet and it does not contain any indication that uterine rupture could potentially prove fatal for mother and / or baby . My concern is that prospective parents may rely on this information leaflet to assist them in making informed choices about their birth options , and that if the risk is not identified then other patients like ████████ might pursue VBAC in circumstances where – if they had understood the risk better – they would have chosen otherwise .
” 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 Review and update the RCOG patient information leaflet on birth after previous caesarean.
Verbatim wording from the response “This RCOG leaflet has been reviewed and updated recently and is due for publication in the very near future.” Source location Response Royal College of Obstetricians & Gynaecologists
Open published response
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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 Publish the recently reviewed and updated RCOG patient information leaflet.
Verbatim wording from the response “This RCOG leaflet has been reviewed and updated recently and is due for publication in the very near future.” Source location Response Royal College of Obstetricians & Gynaecologists
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 The leaflet identifies uterine rupture risks and serious consequences, including stillbirth, although it does not use the word “fatal”.
Verbatim wording from the response “The patient information leaflet Birth after Previous Caesarean², while not using the precise term ‘fatal’ in relation to uterine rupture nonetheless states the risks and that stillbirth can be a serious consequence of VBAC.” Source location Response Royal College of Obstetricians & Gynaecologists
Open published response
Concerns raised 1 Lack of NICE guideline inclusion of the shoulder shrug manoeuvre View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jannat ABBKER · 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
Jannat was a baby who died shortly after birth from trauma suffered during birth as a result of shoulder dystocia. The report states that her mother’s previous shoulder dystocia was not communicated or recognised, and raises a concern that the shoulder shrug manoeuvre used during the delivery is not included in NICE guidelines.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of NICE guideline inclusion of the shoulder shrug manoeuvre
Wider context from the report “However, there remains one outstanding point. When all else had failed, Jannat was finally delivered by use of a manoeuvre called a shoulder shrug. I heard at inquest that this is not a manoeuvre included within the NICE (National Institute for Health and Care Excellence) guidelines , but it is used abroad. One of the obstetric registrars looking after Jannat’s mother had seen it in a training video.
I wonder if there is merit in considering this for inclusion in the next set of relevant NICE guidelines, whenever these are updated?
” 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 Update and publish the Shoulder Dystocia guideline, including an evidence-based section on alternative manoeuvres.
Verbatim wording from the response “The RCOG Green Top Guideline (No. 42) on Shoulder Dystocia is due to be updated and published this year. This update has been in production for the last two years and is undergoing extensive development including comprehensive literature searches, internal and external review, involvement of key stakeholders and liaison with multi-professional specialists and experts. There is no NICE guidance on this topic and national guidelines are produced either by the RCOG or NICE to avoid replication.” Source location Response from Royal College Obstetricians and Gynaecologists
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 National guidelines on shoulder dystocia are produced by either RCOG or NICE, to avoid duplication; the RCOG guideline is being updated.
Verbatim wording from the response “The RCOG Green Top Guideline (No. 42) on Shoulder Dystocia is due to be updated and published this year. This update has been in production for the last two years and is undergoing extensive development including comprehensive literature searches, internal and external review, involvement of key stakeholders and liaison with multi-professional specialists and experts. There is no NICE guidance on this topic and national guidelines are produced either by the RCOG or NICE to avoid replication.” Source location Response from Royal College Obstetricians and Gynaecologists
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 Shoulder shrug cannot currently be recommended because the evidence supporting it is insufficient for inclusion in the evidence-based management algorithm.
Verbatim wording from the response “There are other manoeuvres outside of those listed in the RCOG guidance as reported in the literature, for consideration, when the routine release manoeuvres have been unsuccessful. However, the data and evidence supporting these manoeuvres are extremely limited.” Source location Response from Royal College Obstetricians and Gynaecologists
Open published response
24 Apr 2025 Jacqueline Anne Potter · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 5 Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi View source Failure to provide families with codified risk and safety planning information for first overnight leave View source Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care View source Lack of mandatory menopausal training for relevant clinical practitioners View source Failure to recognise the clinical importance of menopausal symptoms and care View source See 2 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
Jacqueline Anne Potter · 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
Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict in-patient access to self-harm websites through secure unit Wi-Fi
Wider context from the report “(2) It transpired during the Inquest that if an in-patient (detained or voluntary) accesses the secure unit Wi-Fi there are no algorithms or ‘search detection features’ to prevent access to websites pertaining to self harm and so these can be readily accessed by a group who are already vulnerable due to their acute mental health presentation with some element of inherent risk of suicide . It was noted, quite rightly, by legal representatives that workplace organisations can block access to certain sites they deem it undesirable for their workforce to access (such as sites relating to gambling, sexually inappropriate content etc) which shows that it is possible to limit access to certain websites and content when using a Wi-Fi provider. By allowing an already vulnerable group to have unfettered access to websites dedicated to self harm creates a risk of further deaths .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with codified risk and safety planning information for first overnight leave
Wider context from the report “(1) Anne was not sent home for her first overnight leave with any codified ‘Risk’ and ‘Safety Planning’ document. Whilst it was widely accepted in this case that Anne’s husband was well versed and knowledgeable about his wife’s risks and the measures that might be necessary to help keep her safe whilst she was at home, not all families are as involved in their loved one’s psychiatric care, despite the Trust following the Triangle of Care principles.
Whilst families are not mental health practitioners and are not expected to adopt that role within the community there appears to be an opportunity to supply families with a short, codified document dealing with salient points of risks and safety planning when a patient goes for their first overnight leave since being detained . This may equip families with the knowledge to spot signs of declining mental presentation and/or risk and provide them with the knowledge and/or tools to take appropriate steps to assist in safeguarding their loved ones whilst they are in the community.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care
Wider context from the report “(ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations . Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist .
I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory menopausal training for relevant clinical practitioners
Wider context from the report “(i) Certain elements of medicine and clinical practice training are compulsory but having heard evidence at the Inquest around mandatory and statutory training modules I learnt that this covers areas such as GDPR training and disposal of sharp objects such as syringes. I was surprised to learn that menopausal training is not mandatory in any area of clinical practice or specialism . I am concerned that there is no requirement to undertake essential compulsory menopausal training for those working in ‘relevant’ clinical practices such as Mental Health Practice, Obstetrics and Gynaecology and Oncology, or even general as a general GP.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the clinical importance of menopausal symptoms and care
Wider context from the report “I was told during a previous PFD Response relating to menopausal knowledge and care within the NHS that “It is important to ensure that women understand common symptoms such as anxiety, stress and depression which they might experience during the menopause and where and when to seek help. The NHS website has resources….” This emphasises my concerns entirely; the lack of importance given to menopausal symptoms . If someone has concerns about heart disease, a worrying lump, a broken bone etc they expect to be able to consult a medically qualified professional who has a knowledge and understanding of their condition or presentation and can diagnose and treat accordingly; not just [and I paraphrase] ‘have a look at a website to help’.
I appreciate that each and every woman will experience perimenopause and menopause differently, their individual experience is unique to them and this, to some degree, creates difficulties as a ‘one size fits all’ approach (which is perhaps achievable in other medical specialisms and disciplines) cannot be offered, but the lack of recognition of the importance of this condition remains a significant concern . I had previously been told (back in a 2024 PFD response) of a roll-out of specialist menopausal care and upskilling of GPs but there was little evidence during the inquest that this has happened/is happening and women continue to approach and navigate the menopause without the support of expert clinicians or practitioners who understand and can treat the symptoms they are experiencing .
” 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 Provide a Special Interest Training Module covering assessment, investigation and treatment counselling for menopause-related symptoms.
Verbatim wording from the response “The College also has a Special Interest Training Module (SITM) in menopause care. This SITM is aimed at learners with an interest in menopause care. It provides training on how to assess and investigate women with menopause-related symptoms, understand the benefits and risks of HRT and alternative therapies, and counsel and advise women accordingly.” Source location Response from RCOG
Open published response
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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 Embed menopause management in the obstetrics and gynaecology training curriculum and MRCOG examination syllabus.
Verbatim wording from the response “To support doctors in this aim, the RCOG provides educational initiatives, including its curricula on which the MRCOG qualification is based and tested through examinations, elevating care standards through clinical guidance, assisting in career advancement through examinations, coordinating professional development initiatives and events, and offering support services to its members.” Source location Response from RCOG
Open published response
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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 Host recurring menopause-related training and education events accessible to healthcare professionals.
Verbatim wording from the response “Throughout the course of each year the RCOG and our Specialist Society (British Menopause Society) also host numerous training and education events which are accessible to all healthcare professionals, several of which support additional education into various aspects of care for menopausal women.” Source location Response from RCOG
Open published response
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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 Include menopause diagnosis, investigation and management in the DRCOG examination syllabus for interested general practitioners.
Verbatim wording from the response “Additionally, for General Practitioners who would like to develop a more advanced knowledge of women’s healthcare, the RCOG also provides the Diploma of the Royal College of Obstetricians and Gynaecologists (DRCOG). The core syllabus for this examination also includes diagnosis, investigation and management of the menopause. The DRCOG is primarily undertaken by those in General Practice who have an interest in Women’s Health but is not mandatory.” Source location Response from RCOG
Open published response
Concerns raised 1 Insufficient guidance on management actions for abnormal antenatal CTG View source
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
Alonzo Christopher Andrew Wood · 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
Alonzo Christopher Andrew Wood was born on 23 September 2023 and died on 26 September 2023 from multi-organ failure associated with a significant hepatic congenital haemangioma. A spontaneous bleed occurred between 21 September and his birth, leaving him critically unwell at delivery. The report also identified insufficient guidance on management actions following an abnormal antenatal CTG, including whether and when delivery should occur.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance on management actions for abnormal antenatal CTG
Wider context from the report “During the course of the evidence I was informed that the clinicians consider that there is insufficient guidance as to the management actions that should be taken in the event of an abnormal antenatal CTG . In particular, the clinicians indicated that there was no guidance where there has been an abnormal CTG antenatally as to whether delivery should occur and, if so, in what period . As such, the decision making is reliant on individual clinical judgment .
” Open source report
×
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 Clinical variability means strict antenatal CTG protocols cannot cover every situation; individualised care and experienced clinicians’ judgment remain necessary.
Verbatim wording from the response “The variability in clinical scenarios in the antenatal period means that strict protocols or exhaustive guidelines, may not cover every situation, underscoring the importance of individualised care plans developed by experienced clinicians. It cannot be emphasised enough that the complexity and variability inherent in clinical practice necessitate reliance on professional judgment to ensure optimal outcomes for both mother and baby.” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
13 Dec 2024 LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report Essex
View report summary
Concerns raised 16 Lack of compliance with national guidance and training View source Delays in escalating deteriorating maternity patients for senior and critical care review View source Failure to maintain contemporaneous and accurate Labour Ward medication records View source Failure to obtain accounts from Haematology and blood laboratory staff after a massive haemorrhage View source Insufficient experienced doctor skill mix on the Labour Ward View source Omission of covert bleeding from the Trust Drills & Skills Booklet View source Failure to obtain consultant obstetric input, medical review and imaging before therapeutic anticoagulation View source Failure to communicate and share clinical information between Trust staff View source Failure to record Labour Ward vital signs on required MEOWS charts View source Failure to obtain critical care review after Labour Ward administration of Metaraminol View source Failure to trigger the major haemorrhage protocol View source Failure to recognise covert bleeding causing hypovolaemia View source Failure to obtain and retain contemporaneous blood testing results for high-risk or deteriorating patients View source Failure to communicate key information during staff handovers View source Failure to escalate obstetric emergencies to an obstetric consultant View source Failure to consider bleeding as a cause of maternal deterioration View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Support multiprofessional PROMPT skills-and-drills training for maternity teams, reinforcing leadership, communication and situational oversight during emergencies.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024. View source
Action
Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Provide structured handover guidance using SBAR and SHARING tools to improve communication of critical information between maternity teams.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Provide guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source
Action
Provide guidance on reducing venous thromboembolism risk during pregnancy and the puerperium, including anticoagulation decisions when bleeding risk exists.
Stated completedThe respondent said that this action was complete when they made their response on 18 December 2024. View source See 3 more actions
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AI-generated summary
LAURA-JANE KIRSTEN NICOLE SEAMAN · 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
Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of compliance with national guidance and training
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Delays in escalating deteriorating maternity patients for senior and critical care review
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs.
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet.
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous and accurate Labour Ward medication records
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain accounts from Haematology and blood laboratory staff after a massive haemorrhage
Wider context from the report “(12) No accounts were taken from Haematology, or the blood lab team involved with this massive haemorrhage by the Trust or the HSIB (who investigated this case) where massive amounts of blood products were prepared, dispensed and then administered where the timings and sharing of information were important to understand.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient experienced doctor skill mix on the Labour Ward
Wider context from the report “(9) Staff skill mix for doctors on the Labour Ward for the night of 20/21 December was staffed with a junior obstetric registrar with a newly qualified colleague in his first week and a junior anaesthetist, all with limited experience of working on the Labour Ward .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Omission of covert bleeding from the Trust Drills & Skills Booklet
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs.
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet .
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consultant obstetric input, medical review and imaging before therapeutic anticoagulation
Wider context from the report “(11) Therapeutic anticoagulation was administered without consultant obstetric input, further medical review or imaging where there had been hours of deranged vital signs that were inconsistent potential complications for pulmonary embolism.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and share clinical information between Trust staff
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to record Labour Ward vital signs on required MEOWS charts
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain critical care review after Labour Ward administration of Metaraminol
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs .
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet.
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to trigger the major haemorrhage protocol
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise covert bleeding causing hypovolaemia
Wider context from the report “(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect.
(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs.
(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised . The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet .
(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and retain contemporaneous blood testing results for high-risk or deteriorating patients
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching , and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate key information during staff handovers
Wider context from the report “(10) Quality of communication and handovers between Trust staff key information was omitted in handovers between staff at all levels including when Laura-Jane was taken to theatre as a medical emergency.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate obstetric emergencies to an obstetric consultant
Wider context from the report “(6) The Trust Executive Review Group (“ERG”) Report was not shared with the Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital who did not agree with the ERG conclusions that:
‘The absence of escalation to an obstetric consultant was discussed and noted that the team escalated to an anaesthetist, which is usual practice in an obstetric emergency (putting out a call to the medical emergency team would not be common practice).’
‘The possible reasons why the bleeding was not identified were discussed and it was noted that in maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be unlikely that the team would have considered bleeding as a cause of deterioration.’
and gave evidence that this is not in accordance with good clinical practice or national guidelines and training .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to consider bleeding as a cause of maternal deterioration
Wider context from the report “(6) The Trust Executive Review Group (“ERG”) Report was not shared with the Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital who did not agree with the ERG conclusions that:
‘The absence of escalation to an obstetric consultant was discussed and noted that the team escalated to an anaesthetist, which is usual practice in an obstetric emergency (putting out a call to the medical emergency team would not be common practice).’
‘The possible reasons why the bleeding was not identified were discussed and it was noted that in maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be unlikely that the team would have considered bleeding as a cause of deterioration.’
and gave evidence that this is not in accordance with good clinical practice or national guidelines and training .
” 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 Support multiprofessional PROMPT skills-and-drills training for maternity teams, reinforcing leadership, communication and situational oversight during emergencies.
Verbatim wording from the response “The College supports the training run by the PROMPT Foundation which is a multi-professional skills and drills training programme for maternity units helping midwives, obstetricians, anaesthetists and other maternity team members be safer and more effective. This should be undertaken to instil the importance of clear leadership, communication within the wider team and the ability to lead and provide a helicopter view in such scenarios.” Source location Response from Royal College of Obstetricians and Gynaecologists
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 Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
Verbatim wording from the response “2. Maternal Collapse in Pregnancy and the Puerperium⁴ (Green-top Guideline No. 56). Clearly states that: “An obstetric modified early warning score chart should be used for all women undergoing” Source location Response from Royal College of Obstetricians and Gynaecologists
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 Provide structured handover guidance using SBAR and SHARING tools to improve communication of critical information between maternity teams.
Verbatim wording from the response “4. Improving patient handover⁸ (Good Practice Paper No. 12). States that it is important to optimise communication of critical information as an essential component of risk management and patient safety. It goes on to describe two structured tools to use for effective communication between teams to improve the efficiency of communication. The two structured tools described by the RCOG are SBAR (situation – background – assessment – recommendation) and SHARING (Staff, High risk, Awaiting theatre, Recovery ward, Inductions, NICU, Gynaecology). These act as an aide memoir to provide appropriate team updates during handovers.” Source location Response from Royal College of Obstetricians and Gynaecologists
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 Provide guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.
Verbatim wording from the response “5. Good Practice Paper on Roles and responsibilities of the consultant providing acute care in obstetrics and gynaecology⁹ states that one of the general situations in which the consultant must attend is any return to theatre for obstetrics or gynaecology. Some of the other obstetrics reasons for attendance are early warning score protocol or sepsis screening tool that suggests critical deterioration where HDU / ITU care is likely to become necessary or maternal collapse or where ‘major obstetric haemorrhage’ call has been instigated.” Source location Response from Royal College of Obstetricians and Gynaecologists
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 Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
Verbatim wording from the response “The RCOG’s clinical guidance in this context includes the following:” Source location Response from Royal College of Obstetricians and Gynaecologists
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 Provide guidance on reducing venous thromboembolism risk during pregnancy and the puerperium, including anticoagulation decisions when bleeding risk exists.
Verbatim wording from the response “3. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium⁶ (Green-top Guideline No. 37a April 2015) states that: “Low molecular weight heparin (LMWH) should be avoided, discontinued or postponed in women at risk of bleeding after careful consideration of the balance of risks of bleeding and thrombosis.”” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
12 Nov 2024 Lisa Gale · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure of urgent liver function test reporting thresholds to account for pregnancy-specific conditions View source Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lisa Gale · 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
Lisa Gale developed Acute Fatty Liver of Pregnancy (AFLP) and later died despite hospital treatment and intensive care. The report raises concerns that markedly abnormal liver-function results were not urgently communicated because reporting thresholds did not account for pregnancy-specific conditions, resulting in a delay in diagnosing AFLP and starting appropriate treatment.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure of urgent liver function test reporting thresholds to account for pregnancy-specific conditions
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women ;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists ;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate grossly abnormal liver function test results from laboratory staff to clinical staff
Wider context from the report “(1) Blood was taken for liver function tests (LFTs) on admission before her condition was diagnosed;
(2) Lisa’s LFT’s were grossly elevated (normal range in brackets) – ALT 612 (10-50), bilirubin 122 (<21), creatine 168 (45-84);
(3) This was due to a potentially fatal condition – Acute Fatty Liver of Pregnancy – from which she subsequently died;
(3) Despite being grossly elevated, the results once obtained in the laboratory were not phoned through by the laboratory staff to the clinical staff ;
(4) This was because the Royal College of Pathologists’ guidelines for urgent reporting only provides for the same with levels above 750 for ALT, 300 for bilirubin and 354 for creatinine – and does not provide for different reporting levels for those taken in pregnant women;
(5) This is despite pregnancy specific conditions such as AFLP being potentially fatal at much lower levels of abnormal LFTs than those set currently by the Royal College of Pathologists;
(4) As a result there was a delay in diagnosing her AFLP and starting appropriate treatment.
” 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 Review the Royal College of Pathologists’ response to the report regarding pregnancy-specific thresholds for urgent liver-function-test reporting.
Verbatim wording from the response “This case highlights the delay in diagnosis of the severity of condition, resulting from the laboratory not using pregnancy specific levels of liver enzymes for reporting of abnormal results. The guidelines from the Royal College of Pathologists ‘The communication of critical and unexpected pathology results’ (2017) recognises that there are variation in results phoned and suggests that this should be set by local need. The RCOG will review the response from the Royal College of Pathologists following this Regulation 28 Report and ensure that this is appropriately communicated with its members and included within relevant clinical guidance.” Source location Response from Royal College of Obstetricians and Gynaecologists
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 Communicate the review outcome to members and incorporate relevant learning into clinical guidance.
Verbatim wording from the response “This case highlights the delay in diagnosis of the severity of condition, resulting from the laboratory not using pregnancy specific levels of liver enzymes for reporting of abnormal results. The guidelines from the Royal College of Pathologists ‘The communication of critical and unexpected pathology results’ (2017) recognises that there are variation in results phoned and suggests that this should be set by local need. The RCOG will review the response from the Royal College of Pathologists following this Regulation 28 Report and ensure that this is appropriately communicated with its members and included within relevant clinical guidance.” Source location Response from Royal College of Obstetricians and Gynaecologists
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 Responsibility for communicating clinical staff obligations on reviewing electronic results lies with organisations and NHS England or devolved health services.
Verbatim wording from the response “The RCOG however, recognises that there is also an obligation for clinical teams requesting investigations to review the results in a timely manner, depending on the severity of the clinical condition. In the current digital era, laboratory results are available on clinical systems and these should be reviewed by staff caring for the woman. Guidance on the clinician responsibilities is outlined in the GMC Good Clinical Practice 2009, NMC Code of Conduct 2008 and the BMA Acting upon electronic test results (updated in June 2024). Individual trusts/organisations will have specific guidelines applicable to their electronic patient records and it is expected that these, in line with GMC and BMA guidance, would outline the responsibilities of the clinical staff and potential time scales expected.” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
Concerns raised 3 Lack of awareness of hyponatremia developing in birthing women View source Failure to recognise the risk of hyponatremia when giving intravenous fluids View source Failure to keep accurate records of fluid input and output View source
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
Orlando NOVA DAVIS · 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
Orlando Nova DAVIS suffered an irreversible brain injury after his mother developed unrecognised hyponatremia and seizures during labour, restricting oxygen before his birth. He died aged 14 days on 24 September 2021; the principal concerns were a lack of recognition and understanding of hyponatremia among midwives and clinicians, and inaccurate recording of fluid input and output despite additional fluids being given.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of hyponatremia developing in birthing women
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women .
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the risk of hyponatremia when giving intravenous fluids
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women.
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid. Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to keep accurate records of fluid input and output
Wider context from the report “Orlando was caused an irreversible brain injury when his mother suffered a seizure having developed hyponatremia during her labour. The concern is that the midwifes (in the community and in the hosptial, who had cared for Orlando’s mother) were completely unaware of this potential condition developing in birthing women.
In this case due to Orlando developing a tachicardia during labour Orlando’s mothers was actively encouraged to take in more fluid yet there was no accurate record kept of either input or output of fluid . Again when in hospital further fluids were given intravenously with no recognition of any potential risk of hyponatremia developing by the midwives or the Doctor on duty.
” 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 Approach NICE to suggest an addendum to the Intrapartum care guideline addressing hyponatraemia risks, fluid balance monitoring and related neonatal notification.
Verbatim wording from the response “The RCOG is committed to improving the standard of care provided for women by working collaboratively with all stakeholders and in response to this matter, the RCOG will approach NICE to suggest an addendum to their Intrapartum care guideline: NG235 along the following lines:” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
Concerns raised 3 Failure to include Herpes Simplex as a diagnosis to consider in sepsis pathways View source Unclear advice on testing staff during infection investigations View source Lack of guidance on antiviral therapy for postpartum women with signs of systemic infection View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kimberley Sampson and Samantha Mulcahy · 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
Kimberley Sampson and Samantha Mulcahy died after developing disseminated herpes simplex infections acquired before or around delivery, with both progressing to multi-organ failure despite intensive treatment. The principal concerns were delays in recognising a viral cause and commencing antiviral therapy, alongside a lack of national guidance on antiviral treatment for women presenting with systemic infection in the postpartum or peripartum period. The investigation also found uncertainty about testing staff who had treated both women and was unable to establish whether they had a common source of infection.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to include Herpes Simplex as a diagnosis to consider in sepsis pathways
Wider context from the report “(2) Evidence given at the inquest revealed that Herpes Simplex can be fatal if contracted in pregnancy and whilst deaths are rare there is no specific guidance in relation to treating women in the post-partum period with anti-viral therapy. It was accepted by all who gave evidence that antiviral medication would have been recognised treatment for Herpes Simplex (specifically Acyclovir). The Trust has made some minor amendments to its protocols but there is no national guidance either in place back in 2018 or currently in 2023 on prescribing antiviral medication to women who present with signs of systemic infection. Had Acyclovir been prescribed at an earlier stage it is likely to have significantly reduced the risk of death from progression of the disease. Sepsis protocols cover antibiotic therapy but not antiviral therapy. What was abundantly clear from the evidence before the court was that this is a rare but often fatal disease if contracted in the peripartum period and more needs to be done to raise awareness of it as a potential diagnosis to exclude in sepsis pathways and for early consideration of the use to Acyclovir .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Unclear advice on testing staff during infection investigations
Wider context from the report “(1) The inquest heard evidence of steps having been taken to try to establish if the deaths of both women were linked and if there was a common source of infection. In both inquests the women had been treated in separate hospitals but within the same Trust and two members of staff had been involved in treating both women. The inquest heard that Public Health England were involved in the investigation following the deaths and advice on testing staff was unclear which meant neither of the members of staff involved with both women were tested . The inquest was however unable to establish if the strain of the virus was the same in both women as the evidence on this was inconsistent and on balance the evidence did not support a conclusion that both women were infected by the same source.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on antiviral therapy for postpartum women with signs of systemic infection
Wider context from the report “(2) Evidence given at the inquest revealed that Herpes Simplex can be fatal if contracted in pregnancy and whilst deaths are rare there is no specific guidance in relation to treating women in the post-partum period with anti-viral therapy . It was accepted by all who gave evidence that antiviral medication would have been recognised treatment for Herpes Simplex (specifically Acyclovir). The Trust has made some minor amendments to its protocols but there is no national guidance either in place back in 2018 or currently in 2023 on prescribing antiviral medication to women who present with signs of systemic infection . Had Acyclovir been prescribed at an earlier stage it is likely to have significantly reduced the risk of death from progression of the disease. Sepsis protocols cover antibiotic therapy but not antiviral therapy . What was abundantly clear from the evidence before the court was that this is a rare but often fatal disease if contracted in the peripartum period and more needs to be done to raise awareness of it as a potential diagnosis to exclude in sepsis pathways and for early consideration of the use to Acyclovir.
” 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 Update the combined maternal sepsis guideline to include timely identification and treatment guidance for herpes simplex, scheduled for publication in March 2024.
Verbatim wording from the response “The College is currently in the process of updating its Green-top Guidelines on Sepsis in pregnancy (No. 64a) and Bacterial sepsis following pregnancy (No. 64b). The new name of the combined guideline will be Identification and management of maternal sepsis during and following pregnancy (No. 64). We will ensure that this updated version will contain guidance on the timely identification and treatment of herpes simplex. This is currently scheduled for publication in March 2024.” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
16 Sep 2023 Sienna Scarlett Monterio · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Failure to make haemoglobin analysis available in neonatal resuscitation cord blood gas testing View source Lack of national regulation and Newborn Life Support process inclusion for cord blood testing 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
Sienna Scarlett Monterio · 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
Sienna Scarlett Monterio was born by emergency caesarean section on 6 April 2022 and died later that morning following a severe fetal-maternal haemorrhage. The report raises concern that blood gas analysers may not be configured to measure haemoglobin in neonatal resuscitation settings, with variation between trusts potentially limiting information available to clinicians; it states this issue did not contribute to Sienna’s death.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to make haemoglobin analysis available in neonatal resuscitation cord blood gas testing
Wider context from the report “Having reviewed the circumstances surrounding Sienna’s death, the Healthcare Safety Investigation Branch [HSIB] found that at the time of birth the blood gas analyser was not set to analyse the haemoglobin .
The HSIB very clearly state that in the absence of this data , this “prevented other possible causes for the Baby’s condition being considered and possibly corrected.”
The HSIB has also recommended this facility is available in all neonatal resuscitation settings to support the provision of clinical information, and to optimise decision making processes and clinical care.
Sienna was born following an urgent caesarean section, and died within two hours of delivery. Those who work in this area inevitably have to make urgent, life-saving decisions and in the most challenging of circumstances, and it seems to me that there is a lack of clarity on this issue which needs to be addressed. In the absence of such clarity, a baby may die from a preventable cause which is not appreciated by clinicians in the absence of data which would have highlighted a low haemoglobin level in the blood cord gas .
It appears that in some trusts, this data will be readily available, but not in others. If ████████ comment above is correct, there may be different practices within the one trust.
The court has been told that cord blood testing is not regulated or included in the Newborn Life Support (NLS) process at a national level. It appears as though the hospital trust in Blackpool is considering this issue appropriately, and this may reflect the picture nationally.
The HSIB states this data may assist in identifying other possible causes for a baby’s condition being considered, and possibly corrected. ████████ expresses the view that he sees no potential disadvantage in having the Hb measurement being readily available in the cord blood gas from a clinical perspective. I have therefore concluded that there is risk of future deaths and that I therefore have a duty to write this report.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of national regulation and Newborn Life Support process inclusion for cord blood testing
Wider context from the report “Having reviewed the circumstances surrounding Sienna’s death, the Healthcare Safety Investigation Branch [HSIB] found that at the time of birth the blood gas analyser was not set to analyse the haemoglobin.
The HSIB very clearly state that in the absence of this data, this “prevented other possible causes for the Baby’s condition being considered and possibly corrected.”
The HSIB has also recommended this facility is available in all neonatal resuscitation settings to support the provision of clinical information, and to optimise decision making processes and clinical care.
Sienna was born following an urgent caesarean section, and died within two hours of delivery. Those who work in this area inevitably have to make urgent, life-saving decisions and in the most challenging of circumstances, and it seems to me that there is a lack of clarity on this issue which needs to be addressed . In the absence of such clarity, a baby may die from a preventable cause which is not appreciated by clinicians in the absence of data which would have highlighted a low haemoglobin level in the blood cord gas.
It appears that in some trusts, this data will be readily available, but not in others . If ████████ comment above is correct, there may be different practices within the one trust .
The court has been told that cord blood testing is not regulated or included in the Newborn Life Support (NLS) process at a national level . It appears as though the hospital trust in Blackpool is considering this issue appropriately, and this may reflect the picture nationally.
The HSIB states this data may assist in identifying other possible causes for a baby’s condition being considered, and possibly corrected. ████████ expresses the view that he sees no potential disadvantage in having the Hb measurement being readily available in the cord blood gas from a clinical perspective. I have therefore concluded that there is risk of future deaths and that I therefore have a duty to write this report.
” Open source report
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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 4 Lack of training guidance for Keilland’s forceps use View source Lack of guidance on the minimum annual case volume needed to maintain Keilland’s forceps skills View source Lack of clear guidance on alternative management of malrotation and asynclitism after abandonment of Keilland’s forceps View source Insufficient awareness of complications associated with Keilland’s forceps View source See 1 more concern
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
Finley Austin May · 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
Finley Austin May was born on 16 February 2021 after delivery using Keilland’s rotational forceps. He developed a high cervical spinal cord injury caused by the forceps and died at Hull Royal Infirmary on 16 March 2021, aged 28 days. The report raises concerns about complications associated with Keilland’s forceps, the training and skill levels needed for their use, and guidance on alternative methods where trusts no longer use them.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of training guidance for Keilland’s forceps use
Wider context from the report “(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them.
(2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice.
(3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby.
(4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training .
(5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the minimum annual case volume needed to maintain Keilland’s forceps skills
Wider context from the report “(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them.
(2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice.
(3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby.
(4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training.
(5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on alternative management of malrotation and asynclitism after abandonment of Keilland’s forceps
Wider context from the report “(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them.
(2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice.
(3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby.
(4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training.
(5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient awareness of complications associated with Keilland’s forceps
Wider context from the report “(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them.
(2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice.
(3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby.
(4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training.
(5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism.
” 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 Update the Assisted Vaginal Birth guidance after the ROTATE research project concludes.
Verbatim wording from the response “RCOG Green-top Guideline No. 26 on Assisted Vaginal Birth, published in 2020, provides the evidence-based recommendations to support practitioners around use of instruments for assisted vaginal births, and promotes support for the availability of intrapartum ultrasonography for clinicians in their daily practice.” Source location Response from Royal College of Obstetricians and Gynaecologists
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 Add a safety statement to the Kielland’s forceps guidance webpage promoting safe use and experienced supervision.
Verbatim wording from the response “any such serious injury is taken very seriously by the RCOG. We added a safety statement in relation to use of Kielland’s forceps to our guidance on the webpage in June 2023, which states the following:” Source location Response from Royal College of Obstetricians and Gynaecologists
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 The College does not recommend a minimum annual number of Kielland’s forceps cases because training and competence are assessed on a competency-based basis.
Verbatim wording from the response “(4) Continued use of Kielland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training.” Source location Response from Royal College of Obstetricians and Gynaecologists
Open published response
4 May 2022 Lauren Louise MURDOCK · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Miscalculation of clot risk when assessing eligibility for the combined contraceptive pill View source Failure to calculate cardiovascular risk when assessing eligibility for the combined contraceptive pill View source Failure to record significantly elevated blood pressure readings in the medical record View source Failure to bring significantly elevated blood pressure readings to the responsible clinician’s attention View source See 1 more concern
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
Lauren Louise MURDOCK · 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
Lauren Murdock died from a myocardial infarction at age 27. Concerns included a significantly elevated blood pressure reading that was not recorded in her medical record or brought to the GP’s attention, and errors in assessing clot and cardiovascular risks when prescribing the combined contraceptive pill. She died ten days after the elevated blood pressure reading was taken.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Miscalculation of clot risk when assessing eligibility for the combined contraceptive pill
Wider context from the report “The general practitioner (GP) who prescribed Ms Murdock the combined contraceptive pill consulted the UK medical eligibility criteria (MEC) guidelines before she did so.
However, she then miscalculated Ms Murdock’s clot risk and she failed to calculate her cardiovascular risk.
She miscalculated the clot risk because she did not appreciate the difference between a family member with history of clot over the age of 45 years, and one under the age of 45 years . If she had calculated correctly, she would have recognised that Ms Murdock was at higher risk and she would have taken a different course of action.
She failed to calculate the cardiovascular risk because did not notice the relevant box in the MEC guidelines 11 page summary. If she had noticed the box, she would have recognised that Ms Murdock had multiple cardiovascular risk factors (obesity and smoking) and should only be prescribed Dianette following specialist consultation, if at all.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to calculate cardiovascular risk when assessing eligibility for the combined contraceptive pill
Wider context from the report “The general practitioner (GP) who prescribed Ms Murdock the combined contraceptive pill consulted the UK medical eligibility criteria (MEC) guidelines before she did so.
However, she then miscalculated Ms Murdock’s clot risk and she failed to calculate her cardiovascular risk .
She miscalculated the clot risk because she did not appreciate the difference between a family member with history of clot over the age of 45 years, and one under the age of 45 years. If she had calculated correctly, she would have recognised that Ms Murdock was at higher risk and she would have taken a different course of action.
She failed to calculate the cardiovascular risk because did not notice the relevant box in the MEC guidelines 11 page summary . If she had noticed the box, she would have recognised that Ms Murdock had multiple cardiovascular risk factors (obesity and smoking) and should only be prescribed Dianette following specialist consultation, if at all.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to record significantly elevated blood pressure readings in the medical record
Wider context from the report “At inquest, I heard that Lauren visited the practice on 13 October 2021 and saw a healthcare assistant. Her blood pressure was taken and was found to be significantly elevated at 166/90, with a heart rate of 98.
That blood pressure reading does not appear to have found its way to Ms Murdock’s medical record , and it was certainly not brought to Dr ████████ attention.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to bring significantly elevated blood pressure readings to the responsible clinician’s attention
Wider context from the report “At inquest, I heard that Lauren visited the practice on 13 October 2021 and saw a healthcare assistant. Her blood pressure was taken and was found to be significantly elevated at 166/90, with a heart rate of 98.
That blood pressure reading does not appear to have found its way to Ms Murdock’s medical record, and it was certainly not brought to Dr ████████ attention .
” Open source report
13 Dec 2021 Mrs Hurrun Maksur · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Guidance failing to accurately specify point-of-care ultrasound scanning without requiring trauma View source Failure to perform a point-of-care ultrasound scan to exclude intra-abdominal bleeding when pulmonary embolism is suspected View source Failure to incorporate MBRRACE guidance into national obstetric cardiac arrest guidance View source Lack of specific training for obstetricians to identify intra-abdominal bleeding View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Hurrun Maksur · 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
Hurrun Maksur, who was 19 weeks pregnant, suffered a seizure and cardiac arrest after developing severe abdominal pain on 6 June 2020. She was treated for suspected pulmonary embolism, but an intra-abdominal bleed from a ruptured interstitial ectopic pregnancy was subsequently discovered; she died during further surgery on 7 June 2020. Concerns included the failure to perform a FAST scan before thrombolysis, the absence of the guidance from national obstetric cardiac arrest guidance, and specific training for obstetricians to identify intra-abdominal bleeding.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Guidance failing to accurately specify point-of-care ultrasound scanning without requiring trauma
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to perform a point-of-care ultrasound scan to exclude intra-abdominal bleeding when pulmonary embolism is suspected
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate MBRRACE guidance into national obstetric cardiac arrest guidance
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of specific training for obstetricians to identify intra-abdominal bleeding
Wider context from the report “The guidance from MBRRACE UK 2019, provides that:
Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.
A FAST scan did not take place before the diagnosis of pulmonary embolism was confirmed. If the MBRRACE guidance had been followed in this case, it is likely to have prevented the administration of Alteplase in a lady who was suffering from intra-abdominal bleeding.
The 2019 MBRRACE guidance has now been incorporated into the local Trust's resuscitation policy, but has not been incorporated into the National, Resuscitation Council UK, Obstetric Cardiac Arrest guidance.
Concern was raised during the course of the inquest in relation to the reference to the “FAST” scan. It was considered that reference should be to a “Point-of-Care Ultrasound Scan”, as trauma is not a necessary pre-condition for the scan to take place.
Finally, concern was raised during the course of the inquest, that obstetricians do not receive specific training to identify intra-abdominal bleeding.
” 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 Discuss with emergency-medicine and radiology educators the need to check for intra-abdominal bleeding before anticoagulating a collapsed patient.
Verbatim wording from the response “It is our intention to engage in discussions with educators from the Faculty of Emergency Medicine and the Royal College of Radiologists to reinforce the need to check for intra-abdominal bleeding before anticoagulating a collapsed patient.” Source location 2021-0418-Response-from-RCOG_Published
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 Require early-pregnancy ultrasound practitioners to screen for ectopic pregnancy.
Verbatim wording from the response “Screening for ectopic pregnancy is a mandatory part of the ultrasound assessment in early pregnancy. Anyone undertaking a scan in early pregnancy must check for a potential ectopic pregnancy. This is specifically stated in our advice regarding ultrasound training: ultrasound-scan-guidance-vfinal.pdf (rcog.org.uk)” Source location 2021-0418-Response-from-RCOG_Published
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 It is not feasible to train all obstetric doctors to reliably perform FAST scans because routine opportunities and opportunities to maintain competence are insufficient.
Verbatim wording from the response “In A&E, abdominal scanning is usually performed by doctors working within the A&E department who are trained to look for intra-abdominal bleeding; for example in cases of abdominal trauma, ruptured arterial aneurysms etc. It is very rare indeed for an obstetric doctor to be carrying out such a scan within an A&E department and most obstetric doctors would go through their whole hospital career without being asked to perform an ultrasound in these circumstances. Because of the lack of opportunities within routine O&G clinical practice, it would not be feasible to train all our doctors to be able to do this reliably even using simulation. Not only would it be difficult to organise training, they would not be able to retain their skills by regular practice - unlike doctors working in A&E.” Source location 2021-0418-Response-from-RCOG_Published
Open published response
20 Oct 2021 Poppy HARRIS · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 2 Use of Kielland’s forceps View source Failure to complete a birth plan recording the mother’s treatment and care preferences during labour 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
Poppy HARRIS · 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
Poppy Harris was born on 23 November 2020 after a protracted labour and delivery using Kielland’s forceps. She was transferred to John Radcliffe Hospital, where a spinal cord injury was discovered, and she died on 24 March 2021. The substantive concerns were the absence of a birth plan or documented treatment preferences and the use of Kielland’s forceps, which the report states caused a catastrophic spinal cord injury.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Use of Kielland’s forceps
Wider context from the report “2. Poppy was delivered by the use of Kielland’s forceps that resulted in a catastrophic spinal cord injury . I believe the Hospital should carry out an urgent review of the use of Kielland’s forceps and decide that they should no longer be used.
My concern is that this baby died as a result of the use of Kielland’s forceps and there should now be a thorough review of the use of Kielland’s by the college and consideration given to whether it should be used 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a birth plan recording the mother’s treatment and care preferences during labour
Wider context from the report “1. I am concerned that when ████████, Poppy’s Mum, came into the hospital she did not have a birth plan and the midwives did not attempt to complete one . There was therefore no indication as to her preferences for treatment and care throughout her labour .
” Open source report
1 Dec 2020 Brandon-Robert William Collins-Hayward · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Lack of national guidance for close monitoring of mothers and babies following discharge after birth View source Lack of national guidance for medical assessment of a baby when the mother is admitted to hospital with potential sepsis 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
Brandon-Robert William Collins-Hayward · 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
Brandon-Robert William Collins-Hayward was born on 29 May 2019 and died on 7 June 2019, aged 9 days, after developing reduced milk intake, a lip shiver, grumbling noises, jaundice, discharge and breathing difficulties. The principal concerns were the lack of national guidance for observations during early postnatal visits and for assessing a baby when the mother is admitted to hospital with infection or possible sepsis.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for close monitoring of mothers and babies following discharge after birth
Wider context from the report “i. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth , and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis, there could be a death 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for medical assessment of a baby when the mother is admitted to hospital with potential sepsis
Wider context from the report “i. I am concerned that due to the lack of national guidance regarding close monitoring of mothers and babies following discharge after birth, and the fact that there is no national guidance for a medical assessment of a baby when the mother is admitted to hospital with potential sepsis , there could be a death in the future.
” Open source report
9 Oct 2020 Noah Richard Poole · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Lack of professional guidance for vaginal pushes in theatre View source Lack of training for midwives performing vaginal pushes in theatre View source Lack of professional guidance for the use of fetal pillows View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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 Obstetricians and Gynaecologists; 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
×
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 Commission a Scientific Impact Paper on managing impacted fetal head to inform practice.
Verbatim wording from the response “Summary
The RCOG recognises that there is a current dearth in both guidelines and training for the management of IFH and we are committed to addressing this:” Source location 2020-0206-Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-Redacted.pdf
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 Scale impacted fetal head training nationally to improve outcomes.
Verbatim wording from the response “Summary
The RCOG recognises that there is a current dearth in both guidelines and training for the management of IFH and we are committed to addressing this:” Source location 2020-0206-Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-Redacted.pdf
Open published response
2 Mar 2020 HARRY RICHFORD · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 20 Lack of cross-site clinical working opportunities View source Failure to notify the Coroner of a child death View source Uncertain auditing and logging of neonatal resuscitation pro forma completion View source Unclear guidance for obtaining anaesthetic help in paediatric emergencies View source Failure to retain placentae for examination after severe foetal distress View source Lack of clear requirements for consultant assessment of locum competence before overnight responsibility View source Failure to produce timely and sufficiently detailed statements after deaths View source Failure to assess and supervise locum clinicians View source Lack of clarity about when to call a consultant at night View source Failure to record consultant telephone advice View source Failure to record feedback and audit locum recruitment View source Insufficient consultant availability for night-time emergencies View source Lack of staff knowledge of applicable clinical guidelines and policies View source Failure to share important independent safety reports with staff View source Lack of paediatric team knowledge of neonatal collapse guidelines View source Lack of clarity about prompt action in obstetric emergencies View source Substandard obstetric record keeping View source Inaccurate and incomplete child death notification forms View source Inadequate neonatal resuscitation training View source Inaccurate MBRRACE maternal and neonatal death reporting View source See 17 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
HARRY RICHFORD · 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
Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-site clinical working opportunities
Wider context from the report “Concern 8
Prior to Harry's death both ████████████████, a senior member of staff who had the care of Harry at the William Harvey Hospital, accepted that there were no opportunities for cross site working between QEQM and the William Harvey Hospital . Currently two out of eight middle grade doctors have had the opportunity to spend time at the William Harvey, which has a much higher specification neo natal unit. ████████ described the lack of opportunities before Harry's death as ‘at best, very surprising'.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the Coroner of a child death
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected'. No notification was made to the Coroner . No details were filled in on the notification form giving any detail of the problems leading to Harry's death. As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Uncertain auditing and logging of neonatal resuscitation pro forma completion
Wider context from the report “Concern 15
The East Kent Trust should consider a review as to the use or otherwise of a resuscitation pro forma. A pro forma has since Harry's death been adopted by the East Kent Trust which, on the evidence of ████████, has improved the oversight of neo natal training and governance. It is not clear whether that pro forma is being audited or logged , or what actions are being done to ensure its completion and preservation.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Unclear guidance for obtaining anaesthetic help in paediatric emergencies
Wider context from the report “Concern 9
The resuscitation of Harry was eventually carried out by ████████, the anaesthetist looking after ████████. His evidence was that leaving his own patient to help the paediatric team was an unusual action to take in the UK although he had often performed such actions in Nepal. Doctors at QEQM indicated that there was an informal policy that if a middle grade paediatrician found themselves in an emergency, they could seek help from their anaesthetic colleagues . It was unclear whether the anaesthetists were aware of this informal policy . This informal policy should be clarified, and guidance given because there is a risk, that in an emergency, it will be overlooked .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to retain placentae for examination after severe foetal distress
Wider context from the report “Concern 12
The placenta of Harry was not retained . Examination of the placenta will in some circumstances assist in cases of severe foetal distress. The Royal College of Pathologists states that it is 'essential' for the placenta to be sent for examination in cases of severe foetal distress requiring admission to a neo natal unit.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of clear requirements for consultant assessment of locum competence before overnight responsibility
Wider context from the report “Concern 2
The current policy of the East Kent Trust states that it is the responsibility of the healthcare professional who will be supervising the locum to assure themselves of his/her competence. This did not happen in this case. There is at present no requirement for a locum to be assessed on a day shift by a consultant before being left in charge overnight . There is no clear direction that it is the responsibility of the assessing consultant to satisfy themselves of the locum's experience and capability . One specialist from outside the East Kent Trust, ████████, also stated that it would assist the assessing consultants to be able to see not only the locum's CV but also their references and any training records available.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to produce timely and sufficiently detailed statements after deaths
Wider context from the report “Concern 16
In order to try to prevent future deaths it is important that there are clear records and statements made when a death occurs so that lessons can be learnt. In this instance many of the statements were very scanty in their content and some were made a long time after the event . In some instances, staff had to make statements from memory without the advantage of seeing the medical notes . Contemporaneous (or as near as possible) notes are also very much in the interests of the staff involved so that they can give clear accounts of their actions and reasons for them if required to do so at a later date.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and supervise locum clinicians
Wider context from the report “Concern 1
████████ was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital . This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. ████████ gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trusts 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about when to call a consultant at night
Wider context from the report “Concern 5
There appeared to be from the evidence given at the inquest substantial confusion amongst staff as to when a consultant should be called at night . The East Kent Trust now has some 70 hours a week consultant attendance on the wards. That leaves 14 hours a day when there is no consultant present. Staff, whether doctors, nurses or midwives should know the circumstances in which consultant help should be sought and should not feel inhibited from making their views known. If staff are unaware or unsure of when the consultant should be called that potentially poses a continuing risk to life.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to record consultant telephone advice
Wider context from the report “Concern 14
There are no current records kept by consultants who are telephoned at home for advice . In this case there was a dispute about the number of calls made to ████████ and as to the content of these calls. The advice given and the actions taken as a result are important for the preservation of life.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to record feedback and audit locum recruitment
Wider context from the report “Concern 3
████████ had worked two night time shifts at the QEQM before the night of Harry's birth. The extent to which there was any feedback from the consultants on call those two nights to ████████ is unclear. She, erroneously, believed the East Kent Trust had employed ████████. There is no record of any written feedback . From the evidence of the medical director of the East Kent Trust it appears that the current locum recruitment policy is not being checked or audited . There is a potential for further risks to life arising from these shortfalls.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Insufficient consultant availability for night-time emergencies
Wider context from the report “Concern 6
The current contracts at the East Kent Trust permit consultants to live up to 30 minutes travel time from the hospital . This poses considerable problems and risks for night time emergencies .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of applicable clinical guidelines and policies
Wider context from the report “Concern 10
There appeared to be considerable confusion among members of staff as to which, if any, guidelines and policies affected them . While two senior members of staff, ████████████████ (consultant), said that the East Kent Trust has systems in place to ensure knowledge of and compliance with Trust policies neither of them was able to say whether this was effective. Significant issues remain as to the knowledge of staff as to which guidelines govern their behaviour (this was also a finding of the Health and Safety Investigation Board in 2019). Such confusion or lack of knowledge increases the risk of future deaths.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to share important independent safety reports with staff
Wider context from the report “Concern 19
Important independent reports do not appear to have been shared within the East Kent Trust's staff , for instance the HSIB report into Harry's death appeared during the inquest to be unknown to a number of the staff .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of paediatric team knowledge of neonatal collapse guidelines
Wider context from the report “Concern 11
There was a lack of knowledge within the paediatric team of guidelines issued by the Department of Women's Health . The evidence from the East Kent Trust doctors was that the guidelines issued by the department directed to 'all maternity and neonatal staff who may be involved with the immediate care and support of a collapsed neonate' would not have been known to the paediatric team at the relevant time. Even senior clinicians, such as ████████, were not aware of the relevant guidelines.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about prompt action in obstetric emergencies
Wider context from the report “Concern 4
There is a risk to the life of both mothers and babies if there is a lack of clarity as to the processes or the need to take prompt action where it is necessitated in the event of an obstetric concern or emergency developing.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Substandard obstetric record keeping
Wider context from the report “Concern 13
The standard of record keeping on the obstetric unit was substantially sub-standard . The quality of the note taking and records is of considerable importance to new staff taking over responsibility for mother and baby. Without there being clear accurate records there is a risk of further mistakes being made leading, at the worst, to the risk of death. An example of this in Harry's case is that the record of the syntocinon prescribed to ████████ over a long period of time is inconsistent with the evidence of the midwives and the registrar who gave it to her.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete child death notification forms
Wider context from the report “Concern 17
The child death notification form was incorrectly completed in that Harry's death was recorded as 'expected' . No notification was made to the Coroner. No details were filled in on the notification form giving any detail of the problems leading to Harry's death . As a result, the Child Death Overview Panel would have been unaware of the problems encountered and could not have shared learning to prevent other such deaths occurring. I make no recommendation in respect of the lack of notification to the Coroner as I am aware that the Senior Coroner has already dealt with this.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Inadequate neonatal resuscitation training
Wider context from the report “Concern 7
The evidence of ████████ raised substantial concerns about the quality of training and learning in respect of neonatal resuscitation at the East Kent Trust. His evidence was that it would be desirable for middle grade doctors to attend the ARNI course (the advanced resuscitation of the new born infant). He also recommended that there should be simulated drills in neo natal resuscitation.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Inaccurate MBRRACE maternal and neonatal death reporting
Wider context from the report “Concern 18
The MBRRACE form in respect of Harry Richford was inaccurate in a number of important areas . The form is important to provide robust national data to support the delivery of safe, high quality maternal and new born care as well as identifying errors and faults, if any, where there has been a maternal or infant death so that future deaths can be avoided.
” Open source report
30 Jan 2020 Julie Sandra O'Connor · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to accurately report smear test results View source Failure to recognise and appropriately assess an abnormal cervix View source
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
Julie Sandra O'Connor · 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
Julie Sandra O'Connor had a smear test in September 2014 that was reported as normal when it was not, and her cervical cancer was not diagnosed during examinations in August and November 2016. She was diagnosed and treated in March 2017, but her condition deteriorated and she died from metastatic squamous cell carcinoma of the cervix. The report identified concerns about the incorrect smear result and failures to recognise the cancer or the need for further assessment on several occasions.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately report smear test results
Wider context from the report “In this case as well as the fact that the smear test was incorrectly reported there were also 2 occasions when there was a failure to recognise a clinically obvious cancer of the cervix or a failure to recognise a need for further assessment in August and November 2016. In addition the evidence of the experts was that the abnormal appearance of the cervix should also have been diagnosed in February 2017.
The North Bristol NHS Trust have developed a guide for “the management of abnormal cervix, ectropian, and post coital bleeding”* and it is the view of the trust that if this guide had been in place at the time that Julie’s medical condition would have been picked up earlier.
*I attach a copy of the guide produced by the Trust.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and appropriately assess an abnormal cervix
Wider context from the report “In this case as well as the fact that the smear test was incorrectly reported there were also 2 occasions when there was a failure to recognise a clinically obvious cancer of the cervix or a failure to recognise a need for further assessment in August and November 2016. In addition the evidence of the experts was that the abnormal appearance of the cervix should also have been diagnosed in February 2017.
The North Bristol NHS Trust have developed a guide for “the management of abnormal cervix, ectropian, and post coital bleeding”* and it is the view of the trust that if this guide had been in place at the time that Julie’s medical condition would have been picked up earlier.
*I attach a copy of the guide produced by the Trust.
” 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 Work with the BGCS to review training materials for suspected cervical cancer.
Verbatim wording from the response “We all agree that having guidance on senior review of a patient with a suspected cervical abnormality is useful to have at Trust level. If this Trust had had the guidance in place, it may well have prompted the clinician to seek a senior review which may have picked up Julie’s condition at an earlier stage. However, guidance alone may not be sufficient and we will work with the BGCS to review the training materials for suspected cervical cancer, as this is a very visual diagnosis.” Source location 2020-0129-Response-from-Royal-College-of-Obstetricians-and-Gynaecologists_Published.pdf
Open published response
13 Jun 2019 Sebastian Clark · Prevention of Future Deaths report West London
View report summary
Concerns raised 1 Lack of a national programme for screening women in labour for streptococcal infection View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sebastian Clark · 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
Sebastian Clark died on 12 March 2017, four days after his birth, from multiorgan failure and hypoxic ischaemic encephalopathy following acute chorioamnionitis. Concerns included the absence of screening for streptococcal infection in women in labour and the need to consider guidance to reduce similar local deaths.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of a national programme for screening women in labour for streptococcal infection
Wider context from the report “1. I heard evidence that suggested that screening for streptococcal infection in women who were in labour would potentially benefit infants in detecting and interrupting ascending chorioamnionitis infections such as the one that arose in Sebastian Clark. I heard evidence that there was no national programme for such screening in England.
2. Kingston Hospital had subsequently developed a guidance note entitled “Pyrexia and Suspected Chorioamnionitis” in an effort to reduce the prospect of a further death locally. It seemed to me that a policy such as this should be considered by you in an effort to reduce or prevent future deaths. I attach a copy of that document for your information.
” Open source report
18 Jul 2018 Mohamed Rahman · Prevention of Future Deaths report Manchester (West)
View report summary
Concerns raised 6 Failure to contemporaneously document needle insertion and withdrawal times and ultrasound fetal heartbeat monitoring time View source Lack of clinical guidance documents and procedures for unequivocal confirmation of fetal demise View source Lack of a sensitive, lay-language leaflet fully explaining the feticide process to parents View source Diminishing of scans for confirmation of fetal death View source Failure to formally record the exact time of cessation of fetal heart activity View source Failure to perform the interval fetal heart check at least 20 minutes later and for a full 2 minutes 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.
×
AI-generated summary
Mohamed Rahman · 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 Mohamed Rahman was born at 01:45 on 17 February 2018 after an elective feticide procedure and was confirmed dead at 02:48 that day. The principal concerns were that fetal asystole was not unequivocally confirmed before discharge, that the mother and professionals were unprepared for the birth, and that documentation and guidance about confirming fetal demise and explaining the procedure to parents required consideration.
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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to contemporaneously document needle insertion and withdrawal times and ultrasound fetal heartbeat monitoring time
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical guidance documents and procedures for unequivocal confirmation of fetal demise
Wider context from the report “3. Without intending to be prescriptive, it is the opinion that other Departments nationally aware of the tragic sequence of events which took place in Greater Manchester and should consider the implementation of clinical guidance documents and procedures to facilitate unequivocal confirmation of fetal demise .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Lack of a sensitive, lay-language leaflet fully explaining the feticide process to parents
Wider context from the report “4. Consideration should also be given to the desirability of a leaflet for parents which fully explains the feticide process using appropriately sensitive and lay terminology .
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Diminishing of scans for confirmation of fetal death
Wider context from the report “1. Mother in particular but also the experienced professionals involved were wholly unprepared for what they witnessed and the feelings of birth when “stunned”, “shocked” and “distressed” were amongst the epithets given in evidence to describe their experience with the birth. The Neonatal team were not present and would not have expected to be present and had to be called urgently to review what had occurred. However well-intentioned - the attempt to reduce the time that a patient waits for the Department of Fetal Medicine scan is time performed by diminishing the scan for confirmation of fetal death contributed to this unintended outcome after termination of the pregnancy.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to formally record the exact time of cessation of fetal heart activity
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound.
” 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 Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to perform the interval fetal heart check at least 20 minutes later and for a full 2 minutes
Wider context from the report “2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound.
” Open source report
22 Feb 2017 Maxim Karpovich · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Lack of competence in intrapartum CTG interpretation View source
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
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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× 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 Obstetricians and Gynaecologists; 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 Support the electronic fetal monitoring package in collaboration with the Royal College of Midwives and Health Education England.
Verbatim wording from the response “However I should mention here that, as the official host, the RCOG has put a significant amount of resource into supporting the eFM package, working with the Royal College of Midwives and Health Education England.” Source location Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-1
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 A theoretical course for all trainees is considered impractical because trainees struggle to obtain study leave and face extensive mandatory training.
Verbatim wording from the response “Thank you for writing to me on 22 February and 8 March 2017 regarding the inquest of the deaths of Maxim Karpovich and Billy Wilson. I responded to ████████ on 17 March 2017 after meeting and discussing with the RCOG Officers and seeking input and advice from the new Vice Presidents of Education and Clinical Quality. I apologised to ████████ for the delay in my response explaining that I needed to consult with the Curriculum Review team in some detail before I could address his concerns appropriately. The consensus from the RCOG Officers and the Curriculum Review team was that a theoretical course in itself – particularly a course taking place over many weeks as has been suggested – was unrealistic for all trainees, many of whom are struggling to obtain study leave from their Trusts and are also complaining bitterly about the mandatory training modules that they are expected to complete.” Source location Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-1
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 An additional universal CTG course is not considered to enhance safety because the existing curriculum and team-based training arrangements address the relevant risks.
Verbatim wording from the response “In terms of the new curriculum, the pressure of completing modules does not allow us to increase the emphasis on CTG interpretation but it will remain an important that trainees evidence this skill. The RCOG opinion on CTG interpretation is that the problems arise in clinical practice when the whole picture is not considered, and this is why trainees are encouraged to demonstrate clinical competence within teams as part of workplace based assessments. In addition senior trainees who are likely to be in charge of such teams can register for our Advanced Training Skills Module (ATSM) in advanced antenatal practice or advanced labour ward practice, both of which contain curricula that deliver additional training in the teamwork around CTG interpretation which includes the running of team meetings and reviews of decision making.” Source location Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-1
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations