Poppy HARRIS · Prevention of Future Deaths report

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Issued 20 Oct 2021•Milton Keynes

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.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
5

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 raised2

  1. Use of Kielland’s forceps
  2. Failure to complete a birth plan recording the mother’s treatment and care preferences during labour
    Part of recurring concern: Failure to ensure pregnant women have an individualised birth plan

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Milton Keynes University Hospital NHS Foundation Trust

    Review how women’s birth preferences are discussed and documented.

  2. Milton Keynes University Hospital NHS Foundation Trust

    Await the Royal College of Obstetricians and Gynaecologists’ response and determine the hospital’s position on Kielland’s forceps use.

  3. Milton Keynes University Hospital NHS Foundation Trust

    Provide women with online maternity information resources at the 30-week antenatal appointment to prepare for birth-preference discussions.

  4. Milton Keynes University Hospital NHS Foundation Trust

    Facilitate 34-week birth-preference discussions and information access for women with disabilities or who do not speak English as a first language.

  5. Milton Keynes University Hospital NHS Foundation Trust

    Extend 34-week antenatal appointments to one hour for structured discussion and standardised electronic and printed documentation of birth preferences.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Milton Keynes University Hospital NHS Foundation Trust

    Kielland’s rotational forceps should not be removed because experienced practitioners may use them safely and reduce emergency Caesarean risks.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Use of Kielland’s forceps

Wider context from the report

“2. Poppy was delivered by the use of Kielland’s forceps that resulted in a catastrophic spinal cord injury. I believe the Hospital should carry out an urgent review of the use of Kielland’s forceps and decide that they should no longer be used. My concern is that this baby died as a result of the use of Kielland’s forceps and there should now be a thorough review of the use of Kielland’s by the college and consideration given to whether it should be used in the future. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Failure to complete a birth plan recording the mother’s treatment and care preferences during labour

Wider context from the report

“1. I am concerned that when ████████, Poppy’s Mum, came into the hospital she did not have a birth plan and the midwives did not attempt to complete one. There was therefore no indication as to her preferences for treatment and care throughout her labour. ”

Is this part of a recurring concern?

Yes — Failure to ensure pregnant women have an individualised birth plan.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review how women’s birth preferences are discussed and documented.

Verbatim wording from the response

“Following on from Poppy’s inquest – and recognising the need to take stock following on from iterative changes to maternity pathways over the course of the COVID-19 pandemic – we have undertaken a review of how we ensure that women's birth preferences are discussed and documented.”

Source location

Response-from-Milton-Keynes-University-Hospital
Page 2 · response
Published 21 October 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Await the Royal College of Obstetricians and Gynaecologists’ response and determine the hospital’s position on Kielland’s forceps use.

Verbatim wording from the response

“Whilst we naturally seek to take on any learning from Inquest findings, the local Corionial process is not in my view the appropriate route through which to determine future patterns of medical practice. Such decisions require appropriate assessment of risks and benefits of multiple treatment modalities, drawing upon evidence and professional opinion. We will await the response of RCOG to your Regulation 28 report with interest and will determine our position at that point.”

Source location

Response-from-Milton-Keynes-University-Hospital
Page 3 · response
Published 21 October 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide women with online maternity information resources at the 30-week antenatal appointment to prepare for birth-preference discussions.

Verbatim wording from the response

“As part of their routine antenatal care, women are seen by their community midwife at approximately 30 weeks of pregnancy (precise timing varies according to first / subsequent pregnancy), and again at 34 weeks. Going forward, this area will be addressed specifically at these two points. At the 30-week appointment, women will be provided with access (via an internet URL / QR code) to a specific section on the MKUH maternity website where a repository of leaflets relevant to aspects of birth, along with short videos about each of the topics, will be placed.”

Source location

Response-from-Milton-Keynes-University-Hospital
Page 2 · response
Published 21 October 2021

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

Facilitate 34-week birth-preference discussions and information access for women with disabilities or who do not speak English as a first language.

Verbatim wording from the response

“We will ensure that particular care is taken to facilitate this 34-week discussion (and share the underlying information resources) for those with disabilities and/or for whom English is not a first language.”

Source location

Response-from-Milton-Keynes-University-Hospital
Page 3 · response
Published 21 October 2021

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

Extend 34-week antenatal appointments to one hour for structured discussion and standardised electronic and printed documentation of birth preferences.

Verbatim wording from the response

“At 34 weeks, the length of the appointment will be extended from 20 minutes to one hour. In this time, the midwife will complete the routine antenatal checks and discuss the woman's questions, wishes and birth preferences, recording this on a standardised form. The design of the form will have input from the local Maternity Voices Partnership. We will keep abreast of regional and national initiatives and consider reverting to a standardised process as and when established.”

Source location

Response-from-Milton-Keynes-University-Hospital
Page 3 · response
Published 21 October 2021

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

Kielland’s rotational forceps should not be removed because experienced practitioners may use them safely and reduce emergency Caesarean risks.

Verbatim wording from the response

“As you are aware, Kielland’s rotational forceps are used by a subset of obstetricians in England (i.e., the use of Kielland’s rotational forceps is not a required competency for all consultant obstetricians). Their use tends to be concentrated in some units and they may be absent in others. As with most interventions, professional opinion and some evidence supports a relationship between volume and outcomes: in capable and experienced hands, Kielland’s rotational forceps can assist in achieving safe vaginal delivery thus reducing the need for emergency Caesarean section (and the risks that this carries for the mother in particular).”

Source location

Response-from-Milton-Keynes-University-Hospital
Page 3 · response
Published 21 October 2021

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