1 Sep 2016 Ana Geanina SIRGHI-MARIN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to promptly follow up microbiological results from unusually discoloured amniotic fluid View source Failure to obtain immediate microbiological analysis of unusually discoloured amniotic fluid 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
Ana Geanina SIRGHI-MARIN · 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
Ana Geanina Sirghi-Marin died on 29 July 2016 from Escherichia coli sepsis associated with a naturally occurring uterine infection while sixteen weeks pregnant, after undergoing amniocentesis. The principal concern was that unusually dark yellow, non-blood-stained amniotic fluid was not sent for immediate microbiological analysis and promptly followed up, despite the absence of fever or another infection indicator at the time.
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 promptly follow up microbiological results from unusually discoloured amniotic fluid
Wider context from the report “The amniotic fluid drawn off at amniocentesis two days before death was neither purulent nor blood stained, but was discoloured dark yellow.
Given the rarity of such non blood stained discolouration, I heard evidence that it would be a wise precaution in this situation always to send a sample for immediate microbiological analysis, and quickly to follow up the result .
I say always because, at the time of the amniocentesis, there was no fever or other indicator of infection, yet when Ms Sirghi-Marin presented at the emergency unit the following afternoon she was very unwell, and she died the next morning.
Such action would not have changed the outcome in this instance, because presentation to the emergency unit took place approximately 26 hours after the amniocentesis. However, it might in another case. And given the rarity of such non blood stained discoloured amniotic fluid, a guideline that this action is necessary does not seem onerous.
” 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 immediate microbiological analysis of unusually discoloured amniotic fluid
Wider context from the report “The amniotic fluid drawn off at amniocentesis two days before death was neither purulent nor blood stained, but was discoloured dark yellow.
Given the rarity of such non blood stained discolouration, I heard evidence that it would be a wise precaution in this situation always to send a sample for immediate microbiological analysis , and quickly to follow up the result.
I say always because, at the time of the amniocentesis, there was no fever or other indicator of infection, yet when Ms Sirghi-Marin presented at the emergency unit the following afternoon she was very unwell, and she died the next morning.
Such action would not have changed the outcome in this instance, because presentation to the emergency unit took place approximately 26 hours after the amniocentesis. However, it might in another case. And given the rarity of such non blood stained discoloured amniotic fluid, a guideline that this action is necessary does not seem onerous.
” Open source report
30 Jun 2016 baby Dominic Smith · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 14 Failure to act on early warning scores View source Failure to carry out maternal observations after delivery despite a temperature spike View source Failure to recognise signs and symptoms of neonatal deterioration View source Inadequate clinical communication and handover View source Inadequate preceptorship for newly qualified and part-time midwives View source Failure of midwives to escalate to or consult with relevant specialist clinicians View source Failure to carry out speculum examination to establish rupture of membranes View source Failure to document rationale for clinical discretion View source Failure to carry out neonatal observations after material change in condition View source Failure to routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests View source Failure of staff to follow clinical protocols and guidance View source Failure to routinely offer antenatal GBS screening to pregnant women during the final weeks of pregnancy View source Miscalculation of early warning scores View source Inadequate clinical record keeping View source See 11 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
baby Dominic Smith · 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 Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping problems.
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 act on early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon ;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out maternal observations after delivery despite a temperature spike
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature ;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise signs and symptoms of neonatal deterioration
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed ;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical communication and handover
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Inadequate preceptorship for newly qualified and part-time midwives
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure of midwives to escalate to or consult with relevant specialist clinicians
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out speculum examination to establish rupture of membranes
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes . The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to document rationale for clinical discretion
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion ;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out neonatal observations after material change in condition
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition . Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” 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 staff to follow clinical protocols and guidance
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely offer antenatal GBS screening to pregnant women during the final weeks of pregnancy
Wider context from the report “Department of Health, NIHCE and the Royal Colleges:
1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns:
- That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy ,
- That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past)
&
- That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death.
During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action.
I therefore raise the issues again as a concern.
” 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 Miscalculation of early warning scores
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated , ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal College of Obstetricians and Gynaecologists; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical record keeping
Wider context from the report “Pennine Acute Hospitals NHS Trust:
1. During the course of the inquest into Baby Smith’s death, the following concerns arose:
- Inadequate communication, handover and record keeping ;
- Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion;
- Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this;
- Early warning scores were i) miscalculated, ii) not acted upon;
- Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed;
- Maternal observations were not carried out after delivery, despite a spike in temperature;
- Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist
&
- Inadequate preceptorship for newly qualified (and particularly part-time) Midwives.
” Open source report
Concerns raised 7 Failure to accurately record routine observations, fluid balance and gastrointestinal losses View source Failure to make specific obstetric care plans for pregnancy and labour after bariatric surgery View source Failure to provide timely obstetric consultant supervision after emergency admission View source Lack of specific clinical guidance on obstetric care after bariatric surgery View source Failure to act on markedly abnormal urine glucose findings View source Delays in undertaking appropriate investigations for unexplained abdominal pain View source Failure to consider surgical causes of abdominal symptoms after bariatric surgery View source See 4 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
Rhi anne Anoushka Florence BARTON · 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
Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.
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 record routine observations, fluid balance and gastrointestinal losses
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart . No accurate records were kept with regard to fluid intake and urine output . It was not possible to assess the amount, frequency and volume of the vomitus . There was no evidence of diarrhoea despite a diagnosis of gastroenteritis . A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding.
” 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 make specific obstetric care plans for pregnancy and labour after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery . I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians.
” 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 timely obstetric consultant supervision after emergency admission
Wider context from the report “1. Rhi anne’s named obstetric consultant was not informed of her emergency admission . Although there was a consultant obstetrician on the ward on the 11th February there was no request for Rhi anne to be seen and in any event it was not common practice for patients to be seen by another consultant. As such there was no obstetric consultant supervision of Rhi anne from the time of admission until shortly before her surgery; approximately 43 hours after admission .
” 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 clinical guidance on obstetric care after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery. I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians .
” 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 act on markedly abnormal urine glucose findings
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart. No accurate records were kept with regard to fluid intake and urine output. It was not possible to assess the amount, frequency and volume of the vomitus. There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding .
” 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 undertaking appropriate investigations for unexplained abdominal pain
Wider context from the report “3. I also heard evidence that whilst the rarity of an omental band may make it difficult to diagnose there was still a responsibility to exclude other causes of abdominal pain in the absence of an obstetric cause , by undertaking appropriate investigations in a timely fashion .
” 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 surgical causes of abdominal symptoms after bariatric surgery
Wider context from the report “2. No consideration was given to excluding a surgical cause of Rhi anne’s symptoms despite the history of sudden onset of upper abdominal pain in the knowledge that she had had bariatric surgery . I heard evidence that bariatric surgery can, not infrequently, result in an omental/internal hernia causing small bowel obstruction but that it was not widely understood and should be given greater recognition nationally as more women are becoming pregnant following bariatric surgery.
” Open source report
6 Mar 2016 Edward Paddon-Bramley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Inconsistent use of intrapartum antibiotics View source Inconsistent treatment guidance and practice for prolonged rupture of membranes View source Inconsistent GBS screening practice during pregnancy 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
Edward Paddon-Bramley · 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
Edward Paddon-Bramley was born following prolonged rupture of membranes and developed severe infection, including Group B Streptococcus infection. Despite neonatal care, he died aged 9 days. The report identified differing practices and opinions regarding the treatment of prolonged rupture of membranes and whether pregnant women should be screened for Group B Streptococcus and given intrapartum antibiotics.
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 Inconsistent use of intrapartum antibiotics
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” 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 treatment guidance and practice for prolonged rupture of membranes
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” 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 GBS screening practice during pregnancy
Wider context from the report “Evidence was provided to the Court by way of National guidelines (NICE 2008, Induction of labour), Trust guidelines (more than one Trust), The Royal College (Green-top guideline no 36) and by Consultants.
Trust guidelines as to the treatment of prolonged rupture of membranes (PROM) differed from those provided by NICE and the use of anti-biotics, after varying times of rupture, irrespective of the clinical picture.
Consultants views as to the best practice for treating PROM and whether women should be screened for GBS during pregnancy differed from those provided by NICE.
In conclusion, evidence was given at the inquest that there is a difference of opinion and practice in the treatment of mothers (and their babies) who suffer from ROM of a prolonged period. Both clinicians and Trusts appear to be at odds with NICE.
There also appears to be arguable opinion that GBS screening in pregnant women together with the use of intra-partum anti-biotics ought to re-viewed.
” Open source report
23 Oct 2015 Hireiti Kufletsion · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves View source Failure of clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications View source Insufficient clexane dosing for pregnant women with mechanical valves 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
Hireiti Kufletsion · 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
Hireiti Kufletsion died at Queen Elizabeth Hospital Birmingham on 20 November 2014 from thrombosis of a mechanical mitral valve during the first trimester of pregnancy. The report identified failures to adequately investigate the valve, seek specialist cardiology advice and prescribe adequate doses of clexane, with concerns that pregnant women with mechanical heart valves may be at risk from insufficient anticoagulation and inadequate clinical understanding of the associated thrombosis risk.
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 Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose). Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week) . Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa .
” 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 clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications
Wider context from the report “(2) It was apparent from evidence given by clinicians at the Birmingham Heartlands Hospital that they did not understand the extent and gravity of the increased risk of thrombosis to pregnant women with mechanical heart valves and this affected the course of investigations into the deceased’s condition ultimately resulting in a delay in diagnosis until it was too late. Whilst this issue has now been brought to the full attention of all departments within the Birmingham Heartlands Hospital, it is reasonable to assume that there are haematologists, cardiologists and obstetricians without specialist cardio-obstetric knowledge across the country that do not appreciate the implications during pregnancies of patients with a mechanical heart valve for anti-coagulation therapy but maybe involved in the management and care of such patients.
” 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 clexane dosing for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose) . Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week). Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa.
” Open source report
7 May 2015 Baby Olsberg · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 3 Risk of serious harm or death to babies from GBS infection View source Failure to routinely offer prophylactic intrapartum antibiotics to women with current or previous positive GBS tests View source Failure to routinely offer antenatal GBS screening to all pregnant women during the final weeks of pregnancy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Baby Olsberg · 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 Olsberg was born on 23 December 2013 and developed worsening symptoms in the hours after birth. Despite medical treatment and transfer to tertiary care, he suffered three cardiac arrests and died on 24 December 2013; blood cultures confirmed GBS infection. The concerns identified were the lack of routine antenatal GBS screening and routine prophylactic intrapartum antibiotics, and the resulting potential risk of serious harm or death to babies.
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 Risk of serious harm or death to babies from GBS infection
Wider context from the report “3. That GBS infection is a very serious illness and in the absence of a national screening and prophylactic treatment programme, babies are potentially being put at risk of harm/death .
” 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 offer prophylactic intrapartum antibiotics to women with current or previous positive GBS tests
Wider context from the report “2. That prophylactic intrapartum antibiotics are not routinely offered to all women who test positive for GBS (or have done so in the past) .
” 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 offer antenatal GBS screening to all pregnant women during the final weeks of pregnancy
Wider context from the report “1. That antenatal screening for GBS is not routinely offered by the NHS, to all pregnant women, during the final weeks of pregnancy .
” 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 Publish an audit report surveying NHS obstetric units and analysing routinely collected maternity data on Group B streptococcal disease prevention.
Verbatim wording from the response “The RCOG has recently published a report of an audit (https://www.rcog.org.uk/globalassets/documents/guidelines/research--audit/gbs-audit-first-report.pdf) which contains the results of a survey of NHS obstetric units in the UK and analyses of routinely collected maternity data, which you may also find useful.” Source location 2015-0177-Response-by-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 Publish and maintain guidance on preventing early-onset neonatal Group B streptococcal disease.
Verbatim wording from the response “The 2nd edition of the RCOG Green top guideline number 36, Prevention of Early-onset Neonatal Group B Streptococcal Disease was published on 1st July 2012. It gives guidance based on the recommendations of the National Screening Committee.” Source location 2015-0177-Response-by-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 Routine antenatal GBS screening is not recommended because evidence of benefit is insufficient and screening may cause harms and require substantial changes and funding.
Verbatim wording from the response “Point 4.1 in the RCOG guidelines states that Routine bacteriological screening of all pregnant women for antenatal GBS carriage is not recommended.
Until it is clear that antenatal screening for GBS carriage does more good than harm and that the benefits are cost-effective, the National Screening Committee does not recommend routine screening in the UK. Initiating national swab-based screening for antenatal GBS carriage would have a substantial impact on the provision of antenatal care within the UK. Major organisational changes and new funding would be required to ensure an equitable and quality-assured service.” Source location 2015-0177-Response-by-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 Current evidence does not support intrapartum antibiotics for women whose GBS carriage was detected only during a previous pregnancy.
Verbatim wording from the response “Current evidence does not support screening for GBS or the administration of IAP to women in whom GBS carriage was detected in a previous pregnancy.” Source location 2015-0177-Response-by-Royal-College-of-Obstetricians-and-Gynaecologists
Open published response
31 Mar 2015 Thomas Beaty · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Difficulty for Trusts to change guidance without external guidance improvement View source Use of misleading and clinically inappropriate ‘gentle’ traction terminology View source Lack of operational definitions for instrumental-delivery terminology View source Ambiguity in guidance on when to abandon instrumental delivery 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
Thomas Beaty · 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
Thomas Beaty was born by emergency caesarean section after an abandoned instrumental delivery on 11 April 2014. At 26 hours of age, he suffered a catastrophic head injury, hypovolaemic shock and hypoxic brain ischaemia, and died. The report raised concerns that guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, including unclear terminology and misleading guidance about traction.
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 Difficulty for Trusts to change guidance without external guidance improvement
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” 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 misleading and clinically inappropriate ‘gentle’ traction terminology
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” 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 operational definitions for instrumental-delivery terminology
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” 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 Ambiguity in guidance on when to abandon instrumental delivery
Wider context from the report “1. Instrumental Delivery – the Court heard how local/national protocols and
training programmes are routinely based on guidance issued by the Royal College of
Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be
ambiguous, misleading and potentially open to misinterpretation.
A key example was:
‘…When to abandon the procedure:
• No evidence of progressive descent with each pull
• No evidence of imminent birth following 3 pulls of a correctly placed instrument by
an experienced operator…’
The first point by implication must mean that where there is no descent with the first pull, then the
procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction.
2. Terminology - The RCOG Guidance did not provide operational definitions for words such
as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’
case, as it had a bearing on the decision making processes applied during the course of the
forceps delivery.
3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s
protocol was misleading and not in line with the RCOG Guidance. The clinical evidence
suggested that in most (if not all) cases mild to moderate traction is routinely applied by
clinicians in order to ensure safe and successful instrumental delivery. Whilst it was
accepted that this was often subjective, the term ‘gentle’ was clinically out with.
4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until
and unless there is a change/material improvement in the Guidance issued by the RCOG.
” Open source report
16 Feb 2015 infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf) · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Failure to disseminate the Trust’s Interpreting Policy to staff View source Lack of national guidelines for interpreting and classifying antenatal CTG tracings View source Failure of the Trust’s Interpreting Policy to provide applicable guidance on obtaining informed consent View source Failure by staff to apply the Trust’s Interpreting Policy 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
infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf) · 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
Infant Rahat Qayyum was delivered in very poor condition on 5 July 2013 after abnormalities on CTG traces were not fully recognised, and died on 19 July 2013 from hypoxic ischaemic encephalopathy due to or as a consequence of perinatal asphyxia. The concerns identified included the absence of national guidelines for interpreting antenatal CTG tracings and issues concerning the dissemination, application and applicability of the Trust’s Interpreting Policy, particularly in relation to informed consent.
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 disseminate the Trust’s Interpreting Policy to staff
Wider context from the report “2. The dissemination , application and applicability of the Trust’s Interpreting Policy, by its staff , in force at the material time (with particular regard to the obtaining of informed consent).
” 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 guidelines for interpreting and classifying antenatal CTG tracings
Wider context from the report “1. Whilst Pennine Acute Hospitals NHS Trust has now established its own local guidelines based upon recent research conducted in Bristol, there are no national guidelines on how to interpret and/or classify antenatal (as opposed to intra-partum) CTG tracings .
” 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 the Trust’s Interpreting Policy to provide applicable guidance on obtaining informed consent
Wider context from the report “2. The dissemination, application and applicability of the Trust’s Interpreting Policy , by its staff, in force at the material time (with particular regard to the obtaining of informed consent ).
” 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 by staff to apply the Trust’s Interpreting Policy
Wider context from the report “2. The dissemination, application and applicability of the Trust’s Interpreting Policy, by its staff , in force at the material time (with particular regard to the obtaining of informed consent).
” Open source report
24 Oct 2014 Isa Riaz Mushtaq · Prevention of Future Deaths report Manchester (City)
View report summary
Concerns raised 2 Unavailability of fetal blood sampling for antenatal CTG assessment View source Lack of detailed national guidance on antepartum CTG assessment and management 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
Isa Riaz Mushtaq · 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
Isa Riaz Mushtaq was delivered by emergency caesarean section after reduced fetal movement, a suspicious antenatal CTG and fetal bradycardia. He did not recover from the bradycardia/asystole episode, developed severe hypoxic ischaemic encephalopathy and died on the third neonatal day. The principal concern was the absence of detailed national guidance for interpreting and managing abnormal antenatal CTGs, including when urgent delivery is required.
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 Unavailability of fetal blood sampling for antenatal CTG assessment
Wider context from the report “In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken. This is particularly the case for antenatal (non labour) CTG’s since there has not been the same clarification that was provided for electronic intrapartum fetal monitoring by specific NICE guidance. Currently there is no detailed national guidance on antepartum CTG assessment and therefore no guidance as to the circumstances in which CTG changes or abnormalities require urgent delivery. For example, the following problems with antenatal CTG interpretation may arise:-
(i) Should change of position or intravenous fluids be used in the same way as in labour
(ii) What role can be given to iced water drinks or dietary intake to stimulate fetal changes
(iii) At what stage should intervention should be made and with what urgency in the absence of decelerations.
(iv) What significance should be attached to reduced variability and what action should be taken in the absence of decelerations
(v) What significance should be attached to the absence of accelerations where there is reduced variability.
Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:
(i) It is not intended for such use and therefore such practice is arguably not evidence based
(ii) It is much more common for fetal heart traces not to look normal during labour (in the region 20 -30 % outwith normal parameters) therefore the significance of such abnormal traces may not be the same in labour as compared to when identified antenatally.
(iii) Only a very small percentage of antenatal CTG’s are not normal.
(iv) There is no recourse to fetal blood sampling for an antenatal CTG, so that if suspicions persist about lack of fetal well-being there is no way of assessing fetal acid-base balance.
St Mary’s Hospital has now developed its own local guidance for the management of suspected abnormal antenatal CTG in order to mitigate risk. In the absence of uniform, detailed national guidance on antepartum CTG abnormalities St Mary’s hospital has implemented a procedure of early consultant involvement where there are persisting features of unusual CTG.
There should be a review to consider whether national guidance on antepartum CTG monitoring and interpretation where there are abnormalities or unusual features would lead to safer, evidence based management of such cases.
” 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 detailed national guidance on antepartum CTG assessment and management
Wider context from the report “In clinical practice the fetal CTG continues to be a source of problems, both in interpretation and in what degree of action should be taken. This is particularly the case for antenatal (non labour) CTG’s since there has not been the same clarification that was provided for electronic intrapartum fetal monitoring by specific NICE guidance . Currently there is no detailed national guidance on antepartum CTG assessment and therefore no guidance as to the circumstances in which CTG changes or abnormalities require urgent delivery . For example, the following problems with antenatal CTG interpretation may arise:-
(i) Should change of position or intravenous fluids be used in the same way as in labour
(ii) What role can be given to iced water drinks or dietary intake to stimulate fetal changes
(iii) At what stage should intervention should be made and with what urgency in the absence of decelerations.
(iv) What significance should be attached to reduced variability and what action should be taken in the absence of decelerations
(v) What significance should be attached to the absence of accelerations where there is reduced variability.
Reliance on the NICE guidance for intrapartum CTG monitoring to interpret antenatal CTG features is of limited value because:
(i) It is not intended for such use and therefore such practice is arguably not evidence based
(ii) It is much more common for fetal heart traces not to look normal during labour (in the region 20 -30 % outwith normal parameters) therefore the significance of such abnormal traces may not be the same in labour as compared to when identified antenatally.
(iii) Only a very small percentage of antenatal CTG’s are not normal.
(iv) There is no recourse to fetal blood sampling for an antenatal CTG, so that if suspicions persist about lack of fetal well-being there is no way of assessing fetal acid-base balance.
St Mary’s Hospital has now developed its own local guidance for the management of suspected abnormal antenatal CTG in order to mitigate risk. In the absence of uniform, detailed national guidance on antepartum CTG abnormalities St Mary’s hospital has implemented a procedure of early consultant involvement where there are persisting features of unusual CTG.
There should be a review to consider whether national guidance on antepartum CTG monitoring and interpretation where there are abnormalities or unusual features would lead to safer, evidence based management of such cases.
” Open source report
21 Oct 2014 Elsie Sue PLUMB · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Unclear guidance on offering intrapartum antibiotic prophylaxis following earlier GBS colonisation 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
Elsie Sue PLUMB · 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
Elsie Plumb was born full term and died within an hour of delivery from early-onset neonatal sepsis due to Group B streptococcal infection. Her mother had been identified as positive for Group B streptococcus and was recorded as needing antibiotic cover in labour, but this did not happen. The report raised concern that hospital guidance on administering antibiotics and the relevant professional guideline should be clarified.
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 Unclear guidance on offering intrapartum antibiotic prophylaxis following earlier GBS colonisation
Wider context from the report “The consultant obstetrician and gynaecologist gave evidence and indicated that changes had taken place at the hospital to clarify guidance in relation to administering antibiotics to the mother, and when this should be done.
He indicated that the Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 36 titled “The Prevention of Early-onset Neonatal Group B Streptococcal Disease” at paragraph 5.4 on page 4 could be more clearly written .
He stated that the sentence currently reads “If GBS colonisation was identified earlier in the pregnancy (by a swab taken for other reasons) immediate induction of labour and IAP should be offered” .
He suggests that this sentence would be clearer if it were written as follows:
“... immediate induction should be offered. IAP should also be offered, whether or not immediate induction is performed.”
” Open source report
14 Oct 2013 Leo Deady · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to detect breech presentation before delivery View source Lack of national consideration of the risks and benefits of routine late-pregnancy scanning View source Lack of national guidelines on routine late-pregnancy scanning for breech presentation 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
Leo Deady · 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
Leo Deady died at Queen Elizabeth Hospital at one hour of age following an undiagnosed breech presentation, which was first noticed when the mother was fully dilated. The report raised concerns about missed breech presentations, the risks of vaginal breech delivery, and the absence of national guidance on routine late-pregnancy scanning to detect breech presentation.
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 detect breech presentation before delivery
Wider context from the report “(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed . The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high.
Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed .
The only certain way of detecting breech presentation is by scan . The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech. The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy.
There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues.
” 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 consideration of the risks and benefits of routine late-pregnancy scanning
Wider context from the report “(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed. The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high.
Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed.
The only certain way of detecting breech presentation is by scan. The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech. The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy.
There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues .
” 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 guidelines on routine late-pregnancy scanning for breech presentation
Wider context from the report “(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed. The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high.
Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed.
The only certain way of detecting breech presentation is by scan. The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech . The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy.
There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues.
” Open source report
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