Casey Paul GARRETT · Prevention of Future Deaths report

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Issued 30 Jul 2015•Bedfordshire and Luton

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to escalate the level of care when there is a deviation from the norm
    Part of recurring concern: Failure to escalate significant clinical concerns to appropriately senior cliniciansPart of recurring concern: Failure to take timely escalation action when safety thresholds are breached
  2. Unsuitability of the clinical learning environment for Student Midwives
    Part of recurring concern: Unsafe clinical learning environments for trainee midwives
  3. Insufficient fetal monitoring

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Health Education East of England

    Continue collaborating with Bedford Hospital NHS Trust and the University of Bedfordshire to develop an appropriate action plan.

  2. Health Education East of England

    Continue dedicating resources and support to share and adopt learning from the incident across commissioned programmes and provider learning environments.

  3. Health Education East of England

    Monitor post-placement student evaluations, share feedback and support joint remedial action where necessary.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Health Education East of England

    The incident did not reflect wider problems with supervision or education of midwifery students at Bedford Hospital.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Health Education East of England

    Existing supervision, placement auditing, academic support and quality-assurance arrangements support continued use of Bedford Hospital as a clinical learning environment.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to escalate the level of care when there is a deviation from the norm

Wider context from the report

“My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring, mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm”. 1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future. ”

Is this part of a recurring concern?

Yes — Failure to escalate significant clinical concerns to appropriately senior clinicians; Failure to take timely escalation action when safety thresholds are breached.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unsuitability of the clinical learning environment for Student Midwives

Wider context from the report

“My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring, mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm”. 1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future. ”

Is this part of a recurring concern?

Yes — Unsafe clinical learning environments for trainee 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient fetal monitoring

Wider context from the report

“My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring, mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm”. 1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to correctly interpret CTG traces

Wider context from the report

“My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring, mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm”. 1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Continue collaborating with Bedford Hospital NHS Trust and the University of Bedfordshire to develop an appropriate action plan.

Verbatim wording from the response

“HEEoE, since being notified of the incident has been working closely with Bedford Hospital NHS Trust and the University of Bedfordshire to provide input to the development of an appropriate action plan (see attached).”

Source location

2015-0305-Response-by-Health-Education-East-of-England
Page 3 · response
Published 30 July 2015

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 dedicating resources and support to share and adopt learning from the incident across commissioned programmes and provider learning environments.

Verbatim wording from the response

“Health Education East of England will continue to work with both the University of Bedfordshire and Bedford Hospital NHS Trust to ensure the above actions and the attached action plan are delivered. Through the Quality Improvement and Performance Framework, we will continue to dedicate resources and support to ensure the learning from this incident is shared and adopted across all of the commissioned programmes and learning environments within our provider Trusts.”

Source location

2015-0305-Response-by-Health-Education-East-of-England
Page 4 · response
Published 30 July 2015

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

Monitor post-placement student evaluations, share feedback and support joint remedial action where necessary.

Verbatim wording from the response

“Every student completes a post placement evaluation. University of Bedfordshire and HEEoE will monitor these carefully and implement any necessary remedial actions. This will be achieved through increased link-lecturer involvement within the placement area, sharing of student feedback and joint action with Bedford Hospital NHS Trust.”

Source location

2015-0305-Response-by-Health-Education-East-of-England
Page 4 · response
Published 30 July 2015

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 incident did not reflect wider problems with supervision or education of midwifery students at Bedford Hospital.

Verbatim wording from the response

“Following the incident, a full internal investigation was completed by Bedford Hospital NHS Trust and the University of Bedfordshire into the suitability of the learning environment. It was established that the events that had led to the tragic death of Baby Casey Paul Garrett did not reflect any wider issues with the supervision and education of midwifery students at Bedford Hospital. Analysis of current supervision and capacity indicates in excess of a 2:1 ratio of mentors to students, all of whom have undertaken a recent mentorship programme.”

Source location

2015-0305-Response-by-Health-Education-East-of-England
Page 2 · response
Published 30 July 2015

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

Existing supervision, placement auditing, academic support and quality-assurance arrangements support continued use of Bedford Hospital as a clinical learning environment.

Verbatim wording from the response

“Following the incident, a full internal investigation was completed by Bedford Hospital NHS Trust and the University of Bedfordshire into the suitability of the learning environment. It was established that the events that had led to the tragic death of Baby Casey Paul Garrett did not reflect any wider issues with the supervision and education of midwifery students at Bedford Hospital. Analysis of current supervision and capacity indicates in excess of a 2:1 ratio of mentors to students, all of whom have undertaken a recent mentorship programme.”

Source location

2015-0305-Response-by-Health-Education-East-of-England
Page 2 · response
Published 30 July 2015

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026