Concerns raised 5 Staff reluctance to accept confirmation bias and alter practices View source Failure to prioritise relevant staff for confirmation bias training View source Failure of all staff to consider and digest the Newsletters View source Failure of staff to understand confirmation bias View source Delayed completion of confirmation bias training by staff View source See 2 more concerns
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
Clay Daniel Wanckiewicz · 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
Clay Daniel Wanckiewicz was born in very poor condition following failed forceps delivery and caesarean section complicated by a deeply impacted head, and died at 22 minutes of age from skull fractures. The principal concerns were confirmation bias, insufficiently open-minded assessment of the overall clinical picture, inadequate staff training and a continuing risk that similar situations could place mothers and babies at 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 Switalskis Solicitors Limited; that does not assign responsibility.
PFD Monitor interpretation Staff reluctance to accept confirmation bias and alter practices
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a 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 Switalskis Solicitors Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise relevant staff for confirmation bias training
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a 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 Switalskis Solicitors Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of all staff to consider and digest the Newsletters
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a 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 Switalskis Solicitors Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to understand confirmation bias
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a 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 Switalskis Solicitors Limited; that does not assign responsibility.
PFD Monitor interpretation Delayed completion of confirmation bias training by staff
Wider context from the report “(1) Failure of members of staff to understand the concept of confirmation bias.
(2) A reluctance on the part of staff to accept situations of confirmation bias and be open to altering practices.
(3) I am not satisfied the Newsletters had been considered and digested by all staff.
(4) The training program in place is delivered over a 12-month period thus many staff members will not have had that training and there is a risk that confirmation bias situations will continue placing mothers and their babies at risk. Furthermore, some staff members who were involved in Clay’s management were not prioritised to have that training.
These are the reasons for my belief that there continues to be a risk.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations