PFD report

LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report

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Issued 13 Dec 2024•Essex

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.

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Concerns
16

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
23

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 raised16

  1. Lack of compliance with national guidance and training
  2. Delays in escalating deteriorating maternity patients for senior and critical care review
    Part of recurring concern: Failure to escalate significant clinical concerns to appropriately senior cliniciansPart of recurring concern: Failure to reliably recognise and respond to acute clinical deteriorationPart of recurring concern: Failure to reliably recognise when obstetric input is needed and obtain it promptlyPart of recurring concern: Unreliable critical-care outreach for deteriorating patients
  3. Failure to maintain contemporaneous and accurate Labour Ward medication records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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.20

  1. Action

    Support multiprofessional PROMPT skills-and-drills training for maternity teams, reinforcing leadership, communication and situational oversight during emergencies.

    Stated by Royal College of Obstetricians and GynaecologistsStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024.
  2. Action

    Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.

    Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
  3. Action

    Provide structured handover guidance using SBAR and SHARING tools to improve communication of critical information between maternity teams.

    Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.

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

  1. Position

    Metaraminol administration is appropriate for hypotension and does not necessarily indicate severe illness; repeated use should trigger senior anaesthetic or intensive-care review.

    Stated by Mid and South Essex NHS Foundation TrustDisputes 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

Lack of compliance with national guidance and training

Wider context from the report

“(1) The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023 c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts d. Communication issues with Trust staff and sharing of information e. Lack of compliance with national guidance and training f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient g. Lack of compliance with the triggering of the major haemorrhage protocol ”

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

Delays in escalating deteriorating maternity patients for senior and critical care review

Wider context from the report

“(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect. (3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs. (4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet. (5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team. ”

Is this part of a recurring concern?

Yes — Failure to escalate significant clinical concerns to appropriately senior clinicians; Failure to reliably recognise and respond to acute clinical deterioration; Failure to reliably recognise when obstetric input is needed and obtain it promptly; Unreliable critical-care outreach for deteriorating patients.

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 maintain contemporaneous and accurate Labour Ward medication records

Wider context from the report

“(1) The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023 c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts d. Communication issues with Trust staff and sharing of information e. Lack of compliance with national guidance and training f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient g. Lack of compliance with the triggering of the major haemorrhage protocol ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 obtain accounts from Haematology and blood laboratory staff after a massive haemorrhage

Wider context from the report

“(12) No accounts were taken from Haematology, or the blood lab team involved with this massive haemorrhage by the Trust or the HSIB (who investigated this case) where massive amounts of blood products were prepared, dispensed and then administered where the timings and sharing of information were important to understand. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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 experienced doctor skill mix on the Labour Ward

Wider context from the report

“(9) Staff skill mix for doctors on the Labour Ward for the night of 20/21 December was staffed with a junior obstetric registrar with a newly qualified colleague in his first week and a junior anaesthetist, all with limited experience of working on the Labour Ward. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity; Insufficient safe staffing and senior cover out of hours.

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

Omission of covert bleeding from the Trust Drills & Skills Booklet

Wider context from the report

“(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect. (3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs. (4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet. (5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team. ”

Is this part of a recurring concern?

Yes — Failure to recognise and respond to occult internal bleeding; Unsafe management of significant bleeding.

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 obtain consultant obstetric input, medical review and imaging before therapeutic anticoagulation

Wider context from the report

“(11) Therapeutic anticoagulation was administered without consultant obstetric input, further medical review or imaging where there had been hours of deranged vital signs that were inconsistent potential complications for pulmonary embolism. ”

Is this part of a recurring concern?

Yes — Delays in consultant review of patients; Failure to escalate significant clinical concerns to appropriately senior clinicians; Failure to provide effective senior clinical oversight of patient care.

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 communicate and share clinical information between Trust staff

Wider context from the report

“(1) The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023 c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts d. Communication issues with Trust staff and sharing of information e. Lack of compliance with national guidance and training f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient g. Lack of compliance with the triggering of the major haemorrhage protocol ”

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 record Labour Ward vital signs on required MEOWS charts

Wider context from the report

“(1) The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023 c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts d. Communication issues with Trust staff and sharing of information e. Lack of compliance with national guidance and training f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient g. Lack of compliance with the triggering of the major haemorrhage protocol ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable clinical Early Warning Score systems for deterioration.

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 obtain critical care review after Labour Ward administration of Metaraminol

Wider context from the report

“(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect. (3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs. (4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet. (5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team. ”

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 trigger the major haemorrhage protocol

Wider context from the report

“(1) The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023 c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts d. Communication issues with Trust staff and sharing of information e. Lack of compliance with national guidance and training f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient g. Lack of compliance with the triggering of the major haemorrhage protocol ”

Is this part of a recurring concern?

Yes — Unreliable major haemorrhage response arrangements.

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 recognise covert bleeding causing hypovolaemia

Wider context from the report

“(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and national guidance including PROMPT training, or the Royal College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium (RCOG)Green-top Guideline No.56. The maternal collapse was categorised as a “Faint” by Trust staff and Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered medication that had only a transient effect. (3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful delivery and did not prompt a critical care review with a background of deranged vital signs. (4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills Booklet. (5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger Consultant obstetric review, 2222 alert or referral to the critical care outreach team. ”

Is this part of a recurring concern?

Yes — Failure to recognise and respond to occult internal bleeding; Failure to reliably recognise and respond to acute clinical deterioration; Failure to reliably recognise and treat hypovolaemia.

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 obtain and retain contemporaneous blood testing results for high-risk or deteriorating patients

Wider context from the report

“(1) The acute Trust 72-hour investigation did not identify: a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023 c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts d. Communication issues with Trust staff and sharing of information e. Lack of compliance with national guidance and training f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at i. 00:40 hours for cross matching, and ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient g. Lack of compliance with the triggering of the major haemorrhage protocol ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinically required blood tests.

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 communicate key information during staff handovers

Wider context from the report

“(10) Quality of communication and handovers between Trust staff key information was omitted in handovers between staff at all levels including when Laura-Jane was taken to theatre as a medical emergency. ”

Is this part of a recurring concern?

Yes — Unreliable clinical handover processes.

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 escalate obstetric emergencies to an obstetric consultant

Wider context from the report

“(6) The Trust Executive Review Group (“ERG”) Report was not shared with the Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital who did not agree with the ERG conclusions that: ‘The absence of escalation to an obstetric consultant was discussed and noted that the team escalated to an anaesthetist, which is usual practice in an obstetric emergency (putting out a call to the medical emergency team would not be common practice).’ ‘The possible reasons why the bleeding was not identified were discussed and it was noted that in maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be unlikely that the team would have considered bleeding as a cause of deterioration.’ and gave evidence that this is not in accordance with good clinical practice or national guidelines and training. ”

Is this part of a recurring concern?

Yes — Failure to escalate significant clinical concerns to appropriately senior clinicians.

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 consider bleeding as a cause of maternal deterioration

Wider context from the report

“(6) The Trust Executive Review Group (“ERG”) Report was not shared with the Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital who did not agree with the ERG conclusions that: ‘The absence of escalation to an obstetric consultant was discussed and noted that the team escalated to an anaesthetist, which is usual practice in an obstetric emergency (putting out a call to the medical emergency team would not be common practice).’ ‘The possible reasons why the bleeding was not identified were discussed and it was noted that in maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be unlikely that the team would have considered bleeding as a cause of deterioration.’ and gave evidence that this is not in accordance with good clinical practice or national guidelines and training. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration; Unsafe management of significant bleeding.

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

Support multiprofessional PROMPT skills-and-drills training for maternity teams, reinforcing leadership, communication and situational oversight during emergencies.

Verbatim wording from the response

“The College supports the training run by the PROMPT Foundation which is a multi-professional skills and drills training programme for maternity units helping midwives, obstetricians, anaesthetists and other maternity team members be safer and more effective. This should be undertaken to instil the importance of clear leadership, communication within the wider team and the ability to lead and provide a helicopter view in such scenarios.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 4 · response
Published 18 December 2024

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

Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.

Verbatim wording from the response

“2. Maternal Collapse in Pregnancy and the Puerperium⁴ (Green-top Guideline No. 56). Clearly states that: “An obstetric modified early warning score chart should be used for all women undergoing”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 18 December 2024

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

Provide structured handover guidance using SBAR and SHARING tools to improve communication of critical information between maternity teams.

Verbatim wording from the response

“4. Improving patient handover⁸ (Good Practice Paper No. 12). States that it is important to optimise communication of critical information as an essential component of risk management and patient safety. It goes on to describe two structured tools to use for effective communication between teams to improve the efficiency of communication. The two structured tools described by the RCOG are SBAR (situation – background – assessment – recommendation) and SHARING (Staff, High risk, Awaiting theatre, Recovery ward, Inductions, NICU, Gynaecology). These act as an aide memoir to provide appropriate team updates during handovers.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 4 · response
Published 18 December 2024

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

Provide guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.

Verbatim wording from the response

“5. Good Practice Paper on Roles and responsibilities of the consultant providing acute care in obstetrics and gynaecology⁹ states that one of the general situations in which the consultant must attend is any return to theatre for obstetrics or gynaecology. Some of the other obstetrics reasons for attendance are early warning score protocol or sepsis screening tool that suggests critical deterioration where HDU / ITU care is likely to become necessary or maternal collapse or where ‘major obstetric haemorrhage’ call has been instigated.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 4 · response
Published 18 December 2024

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

Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.

Verbatim wording from the response

“The RCOG’s clinical guidance in this context includes the following:”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 18 December 2024

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

Provide guidance on reducing venous thromboembolism risk during pregnancy and the puerperium, including anticoagulation decisions when bleeding risk exists.

Verbatim wording from the response

“3. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium⁶ (Green-top Guideline No. 37a April 2015) states that: “Low molecular weight heparin (LMWH) should be avoided, discontinued or postponed in women at risk of bleeding after careful consideration of the balance of risks of bleeding and thrombosis.””

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 4 · response
Published 18 December 2024

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

Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.

Verbatim wording from the response

“7) An ‘unwell woman’s’ simulation based on antepartum and postpartum haemorrhage including uterine rupture, abruption, and Vasa Previa, as well as a separate simulation on an anaphylaxis scenario was included in the 2023 PROMPT maternity training for all staff in addition to Human factors training, teamwork, situational awareness, and escalation.”

Source location

Response from Mid & South Essex NHS Trust
Page 8 · response
Published 18 December 2024

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

Audit obstetric bleeding-strategy compliance and review postpartum-haemorrhage cases to feed learning to governance and national study teams.

Verbatim wording from the response

“To date, we have 91% training compliance of our target group of clinicians which is being reassessed after a new rotation of staff to ensure we remain above 90%. To assess our compliance of the strategy audits (first 30 consecutive births) and case note reviews (first ten consecutive births with 1 litre loss or more) are undertaken at month one, four, seven and ten after the start of the study. Due to training of staff and development of a standard operating procedure (attached) taking a number of months the strategy did not commence till 21st November 2024 with the last few months taken to drive the uptake of the bundle. To reflect this, the service undertook an additional audit in January which showed a 75% compliance across the board for risk assessments, measured blood loss and appropriate TEG testing.”

Source location

Response from Mid & South Essex NHS Trust
Page 5 · response
Published 18 December 2024

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

Address major-haemorrhage protocol compliance through education, training, amended guidance and monthly monitoring.

Verbatim wording from the response

“Although this concern was not specifically drawn out in the initial Rapid Review, the HSIB report highlighted this as a safety action which has now been addressed through education, training, and the amendment of local guidance.”

Source location

Response from Mid & South Essex NHS Trust
Page 6 · response
Published 18 December 2024

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

Upload patient notes digitally before multidisciplinary meetings so attendees can scrutinise records across meeting formats.

Verbatim wording from the response

“The division acknowledges that the use of multiple medication charts was not included as a specific line of inquiry at the Rapid Review stage, and it should have been. We have reflected on the MDT meeting undertaken for Laura-Jane’s incident and we have made improvements to our processes. We now ensure that patient notes are uploaded as a digital copy in readiness for all MDT meetings so that whether meetings take place in person, online or hybrid, all staff attending have access to review and scrutinise the patient’s notes. Therefore, minimising the risk that important factors such as accuracy and quality record keeping are missed.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 18 December 2024

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

Teach and practise SBAR escalation during annual multidisciplinary PROMPT training.

Verbatim wording from the response

“The obstetric, midwifery and anaesthetic teams have yearly Practical Obstetric Multi Professional Training (PROMPT) training sessions as an MDT where they role play emergency scenarios. Since Laura-Jane’s death, during PROMPT, the teams are taught about the SBAR tool, (Situation, Background, Assessment, Recommendation). Escalation via the use of the SBAR tool is practiced teaching the quality and effectiveness of good communication. SBAR is an easy to remember mechanism to use to frame communications or conversations. It is a structured way of communicating information that requires a response from the receiver. As such, SBAR can be used very effectively to escalate a clinical problem that requires immediate attention, or to facilitate efficient handover of patients between clinicians or clinical teams.”

Source location

Response from Mid & South Essex NHS Trust
Page 3 · response
Published 18 December 2024

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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

Strengthen collaboration with haematology, critical care and anaesthetics, including regular specialty attendance and dedicated ICU consultant input for complex maternal-care reviews.

Verbatim wording from the response

“The service now has an improved working relationship with haematology, critical care, and anaesthetics with regular attendance from these specialties where indicated. The Risk and Governance team now have a dedicated ICU consultant involved in reviewing any complex maternal care.”

Source location

Response from Mid & South Essex NHS Trust
Page 12 · response
Published 18 December 2024

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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

Use electronic prescribing and medication administration records for medications across all Trust sites, except unsupported variable-rate infusions.

Verbatim wording from the response

“All Mid and South Essex Hospital NHS Foundation Trust (‘MSE’) sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record. This aides staff communication as it is clear who has been involved in the prescription of medications, and any queries or escalations can be quickly actioned. A new ‘e-chart’ is automatically started when there is a new patient admission which limits the risk of drug errors and allows for re-evaluation of a patient’s medication.”

Source location

Response from Mid & South Essex NHS Trust
Page 1 · response
Published 18 December 2024

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

Train staff on MEWS charts and eliminate photocopied versions to support accurate scoring and escalation.

Verbatim wording from the response

“Our Rapid Review identified this issue, and several immediate actions were taken including urgent training delivered to staff to increase awareness and improve knowledge of MEWS charts.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 18 December 2024

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

Renew MNSI investigation processes so all involved staff receive draft reports and can provide comments through multidisciplinary factual-accuracy review.

Verbatim wording from the response

“We have now renewed and improved our processes regarding MNSI investigations. The revised processes ensures that all staff involved in the incident are shared the draft report to facilitate the opportunity to comment for factual accuracy and for these comments to be shared with MNSI.”

Source location

Response from Mid & South Essex NHS Trust
Page 12 · response
Published 18 December 2024

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

Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.

Verbatim wording from the response

“The service identified these issues in the initial review of the incident. Since Laura-Jane’s death there has been an implementation of a new MEWS package with escalation policy. This includes the trigger response/medical emergency team once a score of 7 or above is reached.”

Source location

Response from Mid & South Essex NHS Trust
Page 6 · response
Published 18 December 2024

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 escalation work and audit compliance with expected communication standards.

Verbatim wording from the response

“We will continue with this work and monitor compliance with the expected standards by audit.”

Source location

Response from Mid & South Essex NHS Trust
Page 4 · response
Published 18 December 2024

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

Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.

Verbatim wording from the response

“Since August 2024, the maternity unit at Broomfield hospital has begun the implementation of a new obstetric bleeding strategy. The strategy works alongside current PROMPT recommendations of managing a postpartum haemorrhage already in place at the maternity unit.”

Source location

Response from Mid & South Essex NHS Trust
Page 4 · response
Published 18 December 2024

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

Launch the RCOG escalation toolkit, including AID language, conflict-resolution teaching and team-of-shift handover practices.

Verbatim wording from the response

“As part of the Each Baby Counts initiative, the maternity service is launching the Royal College of Obstetricians and Gynaecologists’ (RCOG) ‘Escalation Toolkit’ in February 2025. This toolkit is designed to enhance escalation and improve patient safety and consists of three key components:”

Source location

Response from Mid & South Essex NHS Trust
Page 3 · response
Published 18 December 2024

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

Adopt a rota requiring junior registrars to pair with senior registrars and establish supervision and risk-mitigation arrangements when the intended skill mix is unavailable.

Verbatim wording from the response

“We now have a new rota system in place where the required staffing establishment must include a junior registrar paired with a senior registrar. The junior then has a point of escalation to ensure that any MEWS score of four or above is escalated to the senior registrar and onto the Consultant.”

Source location

Response from Mid & South Essex NHS Trust
Page 11 · response
Published 18 December 2024

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

Metaraminol administration is appropriate for hypotension and does not necessarily indicate severe illness; repeated use should trigger senior anaesthetic or intensive-care review.

Verbatim wording from the response

“The administration of Metaraminol is an appropriate treatment given to someone who is hypotensive. It is not necessarily a marker of how unwell a patient is - a patient may transiently become hypotensive for example following a regional anaesthetic technique (epidural for example) or rapid infusion of IV paracetamol. Its repeated use (because of transient response to the medication) would indicate a problem that needs further investigation and definitive treatment. Therefore, Metaraminol's repeated use should trigger a review by a senior anaesthetic and/or intensive care doctor.”

Source location

Response from Mid & South Essex NHS Trust
Page 9 · response
Published 18 December 2024

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.3

  1. 1

    Provide senior oversight for cases through the Director of Midwifery’s attendance at multidisciplinary meetings and share finalised incident versions appropriately.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
  2. 2

    Provide annual opportunities for midwives to undertake specialist critically unwell-woman and maternity high-dependency training.

    Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024.
  3. 3

    Add a Patient Safety Incident Review Group failsafe to share post-meeting documents and decision sheets with site or service leadership and governance leads.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.

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 senior oversight for cases through the Director of Midwifery’s attendance at multidisciplinary meetings and share finalised incident versions appropriately.

Verbatim wording from the response

“Following the conclusion of the Inquest, a reflective learning exercise was completed by senior colleagues in the service to understand the extent to which the incident investigation was shared within the team. We identified that there were opportunities to improve how complex cases such as this one are shared with colleagues as versions are edited and finalised.”

Source location

Response from Mid & South Essex NHS Trust
Page 10 · response
Published 18 December 2024

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

Provide annual opportunities for midwives to undertake specialist critically unwell-woman and maternity high-dependency training.

Verbatim wording from the response

“Since January 2023, six midwives have attended the Anglia Ruskin University ‘Care of the Critically Unwell Woman’ workshop. Three midwives attended the Maternity HDU course at Kings College London in May 2024.”

Source location

Response from Mid & South Essex NHS Trust
Page 8 · response
Published 18 December 2024

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

Add a Patient Safety Incident Review Group failsafe to share post-meeting documents and decision sheets with site or service leadership and governance leads.

Verbatim wording from the response

“Following the Inquest, we have adapted our process for incidents presented at Patient Safety Incident Review Group (PSIRG). We now have a failsafe to share the post meeting”

Source location

Response from Mid & South Essex NHS Trust
Page 10 · response
Published 18 December 2024

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