PFD report

Jennifer Elisabeth Lestajo CLARK · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 12 Jan 2017•Bedfordshire and Luton

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
1

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

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised1

  1. Lack of adequate neonatal facilities and bed capacity
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Maintain and apply the Neonatal Unit Admissions and Escalation Policy when capacity reaches 90%.

    Stated by West Hertfordshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  2. Action

    Approve redevelopment plans that include development of the neonatal intensive care unit.

    Stated by West Hertfordshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

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

  1. Position

    Existing neonatal capacity, escalation arrangements and regional transfers adequately manage the safety of babies requiring intensive care.

    Stated by West Hertfordshire Teaching Hospitals NHS TrustExisting 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

Lack of adequate neonatal facilities and bed capacity

Wider context from the report

“1. a Consultant Paediatrician from the Hospital, during the course of his evidence, explained that there were over 5,500 births at Watford General Hospital every year, and that the Neonatal Unit only had a limited number of beds and was inadequate for that number of births. Despite having submitted a detailed Proposal for Expansion of the Neonatal Unit, this had been rejected 2. Without adequate neonatal facilities at the Hospital there is a high risk of babies’ lives being at risk 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

Maintain and apply the Neonatal Unit Admissions and Escalation Policy when capacity reaches 90%.

Verbatim wording from the response

“Within the East of England Neonatal Operational Network there are eight units. Department of Health Toolkit for High Quality Neonatal Services¹ suggest that planned capacity should not exceed an average occupancy of 80%. Our aggregate occupancy rate for all cots in 2015 was 69%. The Trust has, since 2015, a Neonatal Unit Admissions and Escalation Policy (enclosed), which sets out what actions are required when the Unit reaches 90% capacity.”

Source location

2017-0001-Response-by-West-Hertfordshire-Hospitals-NHS-Trust
Page 1 · response
Published 19 February 2017

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

Approve redevelopment plans that include development of the neonatal intensive care unit.

Verbatim wording from the response

“Reflecting on the available data and Department of Health guidance set out within the Toolkit, the Trust considers that for the number of births there is adequate facilities available at Watford General Hospital. We do however recognise that the Neonatal Unit, along with many of our buildings, requires modernisation. On 2 February 2017 the Trust Board approved a redevelopment plan as part of the Your Care, Your Future Programme, which will include extensive redevelopment of hospital estates and facilities and this will include plans for development of the NICU. The Trust’s Strategic Outline Case is due to be considered at the Herts Valley Clinical Commissioning Group Board meeting; at the time of writing a date is yet to be set.”

Source location

2017-0001-Response-by-West-Hertfordshire-Hospitals-NHS-Trust
Page 2 · response
Published 19 February 2017

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 neonatal capacity, escalation arrangements and regional transfers adequately manage the safety of babies requiring intensive care.

Verbatim wording from the response

“Based on the latest figures available, in 2015 5451 babies were delivered at Watford General Hospital. The Neonatal Intensive Care Unit (NICU) is a designated Level 2 unit which provides neonatal care for the population within the West Hertfordshire catchment area, except for the sickest babies who require complex or longer-term intensive care in a Level 3 unit. We have a total of 24 cots (3 intensive care cots; 5 high dependency cots and 16 special care cots). Babies requiring Level 3 intensive care are transferred to the nearest Level 3 Intensive Care Unit within our regional neonatal network.”

Source location

2017-0001-Response-by-West-Hertfordshire-Hospitals-NHS-Trust
Page 1 · response
Published 19 February 2017

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 available neonatal facilities are adequate for the number of births, contrary to the concern that inadequate facilities create a high risk to babies.

Verbatim wording from the response

“I am writing to you to respond to the concerns raised by Mr Thomas Osborne’s investigation into the circumstances surrounding the tragic death of Jennifer Clark, which led to him making a regulation 28 report with respect to the issues discussed at the conclusion of the Inquest on 10 January 2017. Mr Osborne was concerned that without adequate neonatal facilities at Watford General Hospital there is a high risk of babies’ lives being at risk in the future.”

Source location

2017-0001-Response-by-West-Hertfordshire-Hospitals-NHS-Trust
Page 1 · response
Published 19 February 2017

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Continue working with Level 3 neonatal intensive care units to ensure the safety of babies requiring intensive care.

    Stated by West Hertfordshire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.

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 working with Level 3 neonatal intensive care units to ensure the safety of babies requiring intensive care.

Verbatim wording from the response

“I hope that the information provided offers assurances that the area highlighted in the prevention of future deaths report is being adequately managed and that there are wider plans that are going to improve services across the whole site for patients who require a variety of the services we are able to offer. We will continue to work with Level 3 Neonatal Intensive Care Units in ensuring the safety of babies born at Watford General Hospital who may require intensive care.”

Source location

2017-0001-Response-by-West-Hertfordshire-Hospitals-NHS-Trust
Page 2 · response
Published 19 February 2017

Open published response
Back to top

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