PFD report

Charlotte Emma Warkcup · Prevention of Future Deaths report

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Issued 29 Sep 2022•Sunderland

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

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 raised3

  1. Insufficient recruitment and retention of midwives for continuity of care
    Part of recurring concern: Failure to provide continuity of care staffingPart of recurring concern: Failure to provide continuity of patient carePart of recurring concern: Unsafe staffing and cover arrangements for midwifery care
  2. Insufficient detection of babies who are small for gestational age
  3. Safety hazard of standalone midwife-led birthing centres without immediate onsite access to a hospital maternity unit
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.6

  1. Action

    Provide non-repayable annual training grants and additional financial support for eligible students and recruitment-shortage specialisms.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
  2. Action

    Implement the NHS People Plan’s staff-retention measures, including wellbeing guardians, healthier working environments, flexible working and psychological support.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
  3. Action

    Develop and apply the Saving Babies’ Lives Care Bundle guidance to support safer maternity care and reduce stillbirths.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.

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

  1. Position

    Evidence indicates freestanding midwifery units are safe for low-risk births, with no significant adverse outcome difference from obstetric units.

    Stated by Department of Health and Social CareDisputes 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

Insufficient recruitment and retention of midwives for continuity of care

Wider context from the report

“2. The recruitment and retention of midwives to ensure continuity of care ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of care staffing; Failure to provide continuity of patient care; Unsafe staffing and cover arrangements for midwifery care.

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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

Insufficient detection of babies who are small for gestational age

Wider context from the report

“3. The improved detection of babies who are of small gestational age ”

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

Safety hazard of standalone midwife-led birthing centres without immediate onsite access to a hospital maternity unit

Wider context from the report

“1. Whether standalone midwife led birthing centres are a safe environment for delivery as opposed to those with immediate onsite access to a maternity unit within a hospital ”

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

Provide non-repayable annual training grants and additional financial support for eligible students and recruitment-shortage specialisms.

Verbatim wording from the response

“And as part of the biggest nursing, midwifery and Allied Health Professional recruitment drive in decades, since September 2020, the Government has made available:”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 October 2022

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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

Implement the NHS People Plan’s staff-retention measures, including wellbeing guardians, healthier working environments, flexible working and psychological support.

Verbatim wording from the response

“To improve working conditions to deter people from leaving the profession, the NHS People Plan has been developed to focus on improving the retention of NHS staff by prioritising staff health and wellbeing. This includes a wellbeing guardian role, a focus on healthy working environments, and empowering line managers to hold meaningful conversations with staff to discuss their wellbeing, and a comprehensive emotional and psychological health and wellbeing support package.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 October 2022

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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

Develop and apply the Saving Babies’ Lives Care Bundle guidance to support safer maternity care and reduce stillbirths.

Verbatim wording from the response

“The Government’s Maternity Safety Ambition is to halve the 2010 rates of stillbirths, neonatal and maternal deaths and brain injuries in babies occurring during or soon after birth by 2025. The ambition also includes reducing the rate of pre-term births from 8% to 6% by 2025.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 7 October 2022

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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

Develop and publish version 3 of the Saving Babies’ Lives Care Bundle with more nuanced risk assessment and clearer practical guidance.

Verbatim wording from the response

“The Saving Babies’ Lives Care Bundle (SBLCB) is a set of guidance that was developed to support progress of the stillbirth element of the ambition, and brings together four key elements of care based on best available evidence and practice in order to help reduce stillbirth rates. This supports commissioners, providers and professionals in making care safer for women and babies. The elements of care brought together by the SBLCB include: Risk assessment and surveillance for fetal growth restriction; Raising awareness of reduced fetal movement; and Effective fetal monitoring during labour.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 7 October 2022

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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

Invest £165 million to grow and support the maternity workforce and improve neonatal care.

Verbatim wording from the response

“The Department recognises that professional staff is the NHS’s most valuable asset, and the importance of ensuring that maternity units have the appropriate number and mix of staff to deliver high quality care for all women.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 October 2022

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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

Expand midwifery training places by 3,650 over four years.

Verbatim wording from the response

“The Government has also committed to expanding midwifery training places by 3,650 over a four-year period with an increase of 650 in September 2019 and 1,000 in each of the subsequent years.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 October 2022

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

Evidence indicates freestanding midwifery units are safe for low-risk births, with no significant adverse outcome difference from obstetric units.

Verbatim wording from the response

“The study found that for 'low risk' women, the incidence of adverse perinatal outcomes was low (4.3 events per 1000 births). For planned births in freestanding midwifery units and alongside midwifery there were no significant differences in adverse perinatal outcomes compared with planned birth in an obstetric unit. Women who planned birth in a midwifery unit (AMU or FMU) had significantly fewer interventions, including substantially fewer intrapartum caesarean sections, and more 'normal births' than women who planned birth in an obstetric unit.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 October 2022

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

    Fund the continuation of 40 mental health hubs across the country.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.

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

Fund the continuation of 40 mental health hubs across the country.

Verbatim wording from the response

“The People Plan is also focused on improving working conditions for staff through flexible working and supporting an inclusive & compassionate workplace culture. £45 million has been invested in 2022/23 to support the continuation of 40 mental health hubs across the country,”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 October 2022

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