PFD report

Eddie Coffey · Prevention of Future Deaths report

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Issued 15 Dec 2020•Hertfordshire

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
13

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 raised4

  1. Failure to establish that training prevents recurrence of the same situation
  2. Use of wrong guidelines for foetal heart rate monitoring in labour
  3. Failure in basic medical care for foetal heart rate monitoring and management during labour
    Part of recurring concern: Failure to provide fetal monitoring when clinically required
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.11

  1. Action

    Procure six standardised CTG machines that record maternal pulse and place the work under capital-committee and risk-register oversight.

    Stated by East and North Hertfordshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021.
  2. Action

    Employ a full-time fetal monitoring specialist midwife to provide guidance, teaching, CTG review and education leadership.

    Stated by East and North Hertfordshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
  3. Action

    Review emerging Ockenden Report findings and recommendations relevant to CTG monitoring.

    Stated by East and North Hertfordshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The Department of Health and Social Care will respond to why 100 maternity units follow the new fetal heart rate monitoring guidelines.

    Stated by East and North Hertfordshire Teaching NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 establish that training prevents recurrence of the same situation

Wider context from the report

“(4) It was not clear from the inquest that, despite training implemented by the Trust since the death, that the same situation would not arise again. ”

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

Use of wrong guidelines for foetal heart rate monitoring in labour

Wider context from the report

“(5) The Evidence was given at the inquest by an independent Consultant Obstetrician that 100 maternity units in the country are following the wrong guidelines in relation to managing foetal heart rate monitoring in labour. ”

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 in basic medical care for foetal heart rate monitoring and management during labour

Wider context from the report

“(2) Evidence was given at the inquest by a Consultant Obstetrician from Lister Hospital that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey might have survived. (3) Evidence was given at the inquest by an independent Consultant Obstetrician that there was a gross failure in the basic medical care provided in the monitoring and management of the foetal heart rate during the labour, and that but for that failure Eddie Coffey would more than likely have survived. ”

Is this part of a recurring concern?

Yes — Failure to provide fetal monitoring when clinically required.

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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 of serious incident investigation to determine directly responsible factors

Wider context from the report

“(1) The Serious Incident Report prepared on behalf of East and North Hertfordshire NHS Trust concluded that the Investigation was unable to determine the factors that were directly responsible for the death of baby Eddie Coffey. This conclusion was directly contradicted by evidence at the inquest. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

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

Procure six standardised CTG machines that record maternal pulse and place the work under capital-committee and risk-register oversight.

Verbatim wording from the response

“Notwithstanding the training that has been implemented already at the Trust, it is accepted that CTG technology is not straightforward. This has led to a review being undertaken of the CTG machines currently in use within the Trust. As a department, Maternity are working towards standardising equipment in line with best practice. Review of the CTG machines currently in use has identified that 6 new machines are required which would then mean that all of the machines in use are the same and all would record maternal pulse on the CTG trace. Further work towards the procurement of these machines is ongoing and being reviewed by our Capital Equipment Committee. This issue will be added to the risk register which will ensure oversight and enable clear monitoring on a regular basis.”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 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

Employ a full-time fetal monitoring specialist midwife to provide guidance, teaching, CTG review and education leadership.

Verbatim wording from the response

“In order to mitigate against this risk, the Trust is committed to enhancing our already well established Fetal Monitoring training and in particular enhancing the training provided to staff with regards to the second stage of labour. The importance of this issue is highlighted in every Fetal Monitoring lecture as maternal pulse features and characteristics are included as well as being included in an element of the Human Factors training that is given. The intended impact of this is to ignite professional curiosity and to encourage clinicians to actively seek out to exclude maternal pulse. Furthermore, since 20 January 2020 the trust has employed a full time fetal monitoring specialist midwife for 12 months.”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 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

Review emerging Ockenden Report findings and recommendations relevant to CTG monitoring.

Verbatim wording from the response

“We have also reviewed the emerging findings and recommendations from the first Ockenden Report in their ongoing review of Maternity Services at Shrewsbury and Telford Hospital Trust published in December 2020. As you may already be aware, one action in this report relates”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 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

Establish a standard operating procedure for LMNS oversight of serious incident investigations and action plans.

Verbatim wording from the response

“the Directors of Midwifery and the LMNS Programme Lead have agreed a standard operating procedure for LMNS oversight of SI investigations and action plans going forward.”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 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

Introduce a CTG-machine sticker requiring two independent maternal-pulse checks and signatures after transfer from MLU to CLU.

Verbatim wording from the response

“Moreover, in terms of immediate practical steps taken, we are in the process of producing a visual sticker that will go at the front of a CTG machine after a woman is transferred from MLU to CLU. This sticker will include a box for two individuals to check and sign that they have independently palpated maternal pulse. This process will be in place by the end of February 2021.”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 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

Obtain future independent clinical opinions under formal terms of reference.

Verbatim wording from the response

“When obtaining an independent third-party or independent clinical opinion in the future the trust will ensure this is done on a more formal basis with clear terms of reference.”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 1 · response
Published 7 January 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

Roll out an intermittent auscultation and escalation competency package with case scenarios, small-group and annual training, competency assessment and pass-rate auditing.

Verbatim wording from the response

“In response to your fourth point, actions have been developed to further strengthen the training in relation to second stage fetal monitoring interpretation. A second stage training update was delivered on 19 January 2021 which focussed on fetal monitoring and recognising the signs to differentiate between maternal pulse and fetal heart rate, highlighting learning from themes and incidents. Further sessions have been planned in this regard. An Intermittent Auscultation and escalation competency package, using added case scenarios including small group sessions and annual training, is being rolled out to the Midwifery-Led-Unit (MLU) midwives supported by a plan to role this out to all midwives. This will include a competency - based assessment and a requirement to record pass rates for ongoing auditing and assurance.”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 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

Develop and implement planned CTG interpretation and escalation actions to establish a robust process.

Verbatim wording from the response

“to CTG monitoring with a number of elements in relation to the management of CTG interpretation and escalation. We have planned for a number of actions going forward in order to ensure that we have a robust process in place in respect of these. Please see the attached excel spreadsheet for full sight of the CTG action plan, some of which are detailed above and the work is ongoing.”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 3 · response
Published 7 January 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

Enhance fetal monitoring training, including second-stage labour interpretation, maternal-pulse recognition, human factors and incident learning.

Verbatim wording from the response

“In order to mitigate against this risk, the Trust is committed to enhancing our already well established Fetal Monitoring training and in particular enhancing the training provided to staff with regards to the second stage of labour. The importance of this issue is highlighted in every Fetal Monitoring lecture as maternal pulse features and characteristics are included as well as being included in an element of the Human Factors training that is given. The intended impact of this is to ignite professional curiosity and to encourage clinicians to actively seek out to exclude maternal pulse. Furthermore, since 20 January 2020 the trust has employed a full time fetal monitoring specialist midwife for 12 months.”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 2 · response
Published 7 January 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

Award £9.4 million to support maternity safety pilots using investigation and research learning, training and expert guidance to improve childbirth practice.

Verbatim wording from the response

“In addition, £9.4million was awarded in the 2020 Spending Review to support maternity safety pilots that will include fresh learning from recent investigations and academic research to be used to improve clinical practice during childbirth, and cutting-edge training and expert guidance to improve practice and avoid harm to babies.”

Source location

2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Page 3 · response
Published 7 January 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

Bring the coroner’s report to the attention of the Healthcare Safety Investigation Branch.

Verbatim wording from the response

“Finally, my officials have brought your report to the attention of the Healthcare Safety Investigation Branch (HSIB). HSIB is a key part of our commitment to improve patient safety and the culture of learning in the NHS. The HSIB conduct independent maternity investigations that meet the Each Baby Counts criteria and a defined criteria for maternal deaths so that the NHS learns quickly from what went wrong and uses this to prevent future tragedies. Where HSIB identifies systemic risks, it can consider making national recommendations for system change.”

Source location

2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Page 4 · response
Published 7 January 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

The Department of Health and Social Care will respond to why 100 maternity units follow the new fetal heart rate monitoring guidelines.

Verbatim wording from the response

“Lastly, I note your area of concern relating to why 100 maternity units in the country are following the new guidelines in relation to managing fetal heart rate monitoring following the evidence you heard from ████████ at the Inquest. I am aware that the Department of Health and Social Care will be responding to you on this point however I hope the contents of this letter demonstrates the relevant actions that the Trust have taken in relation to this.”

Source location

2020-0287-Response-from-Lister-Hospital-Redacted
Page 3 · response
Published 7 January 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

NHS Trusts are responsible for implementing the Saving Babies’ Lives Care Bundle and appointing fetal-monitoring leads.

Verbatim wording from the response

“In relation to monitoring fetal wellbeing, NHS Trusts are being asked to implement the saving babies lives bundle. Element 4 of the Saving Babies Lives Care Bundle Version 2 (SBLCBv2)⁶ already states there needs to be one lead with the responsibility of improving the standard of fetal monitoring. NHS Trusts are now being asked to ensure that a second lead is identified so that every unit has a lead midwife and a lead obstetrician in place to lead best practice, learning and support. This will include regular training sessions, review of cases and ensuring compliance with the SBLCBv2 and national guidelines.”

Source location

2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Page 3 · response
Published 7 January 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

NHS providers and local health partners are responsible for implementing the Patient Safety Incident Response Framework and supporting standards.

Verbatim wording from the response

“NHSEI is currently working with early adopters to pilot the new Framework. The learning from this pilot will be used to inform the final version of the Framework. Until this is finalized, NHS providers and their local health partners should review the introductory framework and Patient Safety Incident Investigation standards⁴ and begin to consider what they will need to do to support their implementation.”

Source location

2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Page 2 · response
Published 7 January 2021

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.2

  1. 1

    Require NHS trusts to publish deaths linked to care problems quarterly and report learning and preventive actions annually in Quality Accounts.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
  2. 2

    Bring the coroner’s report to the attention of health system leaders, NHS England and NHS Improvement.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.

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

Require NHS trusts to publish deaths linked to care problems quarterly and report learning and preventive actions annually in Quality Accounts.

Verbatim wording from the response

“From 2017-18, we have required NHS trusts to publish locally the numbers of deaths thought to be due to problems in care on a quarterly basis, and to evidence what they have learned and the actions taken to prevent such deaths on an annual basis in their Quality Accounts. This new level of transparency is fundamental to a culture of learning and ensuring the safety of NHS services. This policy is supported by strengthened inspection assessment of NHS trusts’ learning from deaths by the independent regulator for quality, the CQC.”

Source location

2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Page 2 · response
Published 7 January 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

Bring the coroner’s report to the attention of health system leaders, NHS England and NHS Improvement.

Verbatim wording from the response

“I welcome the action that has been taken so far and I encourage the Trust to continue to look carefully at what more can be done to improve this important area of patient safety. In line with regulatory processes, I am assured that the CQC will continue to monitor improvements at the Trust and my officials have brought your report to the attention of health system leaders, NHS England and NHS Improvement (NHSEI).”

Source location

2020-0287-Response-from-Dept.-for-Health-and-Social-Care-Redacted
Page 2 · response
Published 7 January 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