PFD report

Lincoln James BRADY · Prevention of Future Deaths report

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Issued 23 Mar 2016•Teesside

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised1

  1. Failure to investigate discordant abdominal and vaginal examination findings to confirm fetal presentation
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.7

  1. Action

    Implement the presentation-scanning SOP for induction admissions and extend it to all women admitted in or suspected of being in labour after training completion.

    Stated by South Tees Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 March 2016.
  2. Action

    Update breech policies and guidance to require scanning where presentation is uncertain, senior clinical involvement, informed consent and specified delivery-management practices.

    Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2016.
  3. Action

    Train midwives in presentation scanning, including equipment use, supervised cases and certification, with completion scheduled for June 2016.

    Stated by South Tees Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 March 2016.

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

  1. Position

    Existing Trust scanning policies and safety measures are considered sufficient to alleviate the identified concerns and exceed national standards.

    Stated by South Tees Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Failure to investigate discordant abdominal and vaginal examination findings to confirm fetal presentation

Wider context from the report

“At 02.40 on 26 August 2014 whilst in labour Mrs Brady was subjected to an abdominal and a vaginal examination. The results of the examination did not correlate. Despite this fact no further investigations, to include an ultrasound scan, were undertaken to confirm Lincoln’s presentation. This resulted in Mrs Brady being considered a low risk delivery and a breech position not being diagnosed. In turn this precluded appropriate planning regarding a preferred method of delivery. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 presentation-scanning SOP for induction admissions and extend it to all women admitted in or suspected of being in labour after training completion.

Verbatim wording from the response

“The inquest would have heard that a Standard Operating Procedure (SOP) for presentation scanning was implemented in March 2016, the details of which are set out below. Currently, all high and low risk women who are admitted for induction of labour have a presentation scan. This has been the case since September 2015. By June 2016, when all training will be completed, the SOP will apply to all women who are admitted in labour or who are suspected to be in labour. The SOP sets out the following:”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 4 · response
Published 23 March 2016

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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

Update breech policies and guidance to require scanning where presentation is uncertain, senior clinical involvement, informed consent and specified delivery-management practices.

Verbatim wording from the response

“Policies and guidelines”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 3 · response
Published 23 March 2016

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 midwives in presentation scanning, including equipment use, supervised cases and certification, with completion scheduled for June 2016.

Verbatim wording from the response

“All midwives working in areas where there is induction of labour or admissions of women suspected to be in labour are to be trained in the technique of scanning for presentation by June 2016. Approximately 50 midwives have commenced and in fact almost completed their training, which commenced in September 2015. Midwives have been trained in the skill of carrying out and interpreting the results of a presentation scan using the equipment that was already available on the unit. Now that the additional handheld machines are available, staff are being trained in the practical use of the scanner, although skill in clinical interpretation of the scan is transferable to the new machines.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 4 · response
Published 23 March 2016

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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

Maintain midwives’ scanning competency through annual evidence requirements and supervised retraining when skills are not maintained.

Verbatim wording from the response

“• The skills maintenance programme is as follows:”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 5 · response
Published 23 March 2016

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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

Update labour and induction guidelines to reflect presentation-scanning requirements.

Verbatim wording from the response

“The relevant guidelines to accompany Trust policy on the first stage of labour and induction of labour were updated in March 2016 to reflect the requirement for presentation scanning. Furthermore, the information around presentation scanning available to women via the Trust website will be updated to reflect the new policy on this issue.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 5 · response
Published 23 March 2016

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

Purchase and distribute eight handheld ultrasound scanners to maternity wards for presentation scanning.

Verbatim wording from the response

“The aim of the programme, as set out in September 2015, was to ensure that all midwives have the ability to perform abdominal scans to determine the presentation of the baby at the onset of labour or on induction of labour, with a view to reducing the risk of undiagnosed breech presentations. For this purpose, 8 hand-held ultra sound scanners were purchased and distributed to the maternity wards across the Trust in April 2016.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 4 · response
Published 23 March 2016

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 Lincoln’s Rule, including red flags and a low threshold for presentation scanning when clinical findings are uncertain.

Verbatim wording from the response

“Through this medium, in September 2014, staff were reminded of the importance of seeking input from senior clinicians at an early stage where there are clinical concerns. This was followed in October 2014 with a further bulletin regarding the importance of altering senior clinicians where there are concerns about clinical findings. Specifically in January 2015, 'Lincoln's Rule' was implemented, urging staff to adopt a low threshold when considering the use of a presentation scan where there is any doubt about clinical findings. Lincoln's Rule also highlighted 4 red flags that should prompt further investigation, specifically drawing from the issues that were noted in this case. These were:”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 2 · response
Published 23 March 2016

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Existing Trust scanning policies and safety measures are considered sufficient to alleviate the identified concerns and exceed national standards.

Verbatim wording from the response

“All of the above actions are subject to continued audit and review, the Trust being committed to continued learning and development of practices and procedures. We trust that the actions outlined above, which we reiterate were in place prior to the hearing, are not only sufficient to alleviate the concerns set out in the Regulation 28 report, but also demonstrate that the steps taken to improve patient safety outcomes as a result of this case go beyond national clinical practice guidelines and standards.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 5 · response
Published 23 March 2016

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.6

  1. 1

    Disseminate risk-management meeting minutes and monthly learning bulletins to clinical staff.

    Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2016.
  2. 2

    Continue auditing and reviewing the safety measures while developing maternity practices and procedures.

    Stated by South Tees Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 March 2016.
  3. 3

    Update the Trust website information for women to reflect the new presentation-scanning policy.

    Stated by South Tees Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 March 2016.
  4. 4

    Deliver an upright breech study day for Trust doctors and midwives, covering delivery techniques, consent and assistance during abnormal labour.

    Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2016.
  5. 5

    Run an amended upright vaginal-breech simulation programme every two weeks, require annual clinical-staff attendance and audit compliance.

    Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 March 2016.
  6. 6

    Participate in the Regional Maternity Patient Safety Network and disseminate lessons learned regionally.

    Stated by South Tees Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 March 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    National admission-scanning policy cannot be implemented without sufficient equipment, training and competency-maintenance resources across the NHS.

    Stated by South Tees Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    NICE or the Department of Health must consider and address national scanning-policy changes because of their NHS-wide resource implications.

    Stated by South Tees Hospitals NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Disseminate risk-management meeting minutes and monthly learning bulletins to clinical staff.

Verbatim wording from the response

“As you will see from the information set out below, determination of presentation will no longer be confirmed without the use of scanners in any event. Nevertheless, important lessons were learned by the Trust on this point. Had the inquest heard ████████ evidence, it would be known that this incident was explored in detail in the department's risk management meetings, which are open to all members of clinical staff. Specifically, the obstetric and midwifery risk management leads and unit managers regularly attend along with representatives from the neonatal and anaesthetic disciplines. The minutes from each meeting are disseminated to all clinical staff along with a 'risky business' monthly bulletin that reinforces key points of learning.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 2 · response
Published 23 March 2016

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 auditing and reviewing the safety measures while developing maternity practices and procedures.

Verbatim wording from the response

“All of the above actions are subject to continued audit and review, the Trust being committed to continued learning and development of practices and procedures. We trust that the actions outlined above, which we reiterate were in place prior to the hearing, are not only sufficient to alleviate the concerns set out in the Regulation 28 report, but also demonstrate that the steps taken to improve patient safety outcomes as a result of this case go beyond national clinical practice guidelines and standards.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 5 · response
Published 23 March 2016

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

Update the Trust website information for women to reflect the new presentation-scanning policy.

Verbatim wording from the response

“The relevant guidelines to accompany Trust policy on the first stage of labour and induction of labour were updated in March 2016 to reflect the requirement for presentation scanning. Furthermore, the information around presentation scanning available to women via the Trust website will be updated to reflect the new policy on this issue.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 5 · response
Published 23 March 2016

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

Deliver an upright breech study day for Trust doctors and midwives, covering delivery techniques, consent and assistance during abnormal labour.

Verbatim wording from the response

“In respect of the concerns around appropriate planning for dealing with breech presentation, the Trust has taken various measures to enhance that training and skills base around breech deliveries, all of which would have been outlined by ████████.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 2 · response
Published 23 March 2016

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

Run an amended upright vaginal-breech simulation programme every two weeks, require annual clinical-staff attendance and audit compliance.

Verbatim wording from the response

“An amended training programme to enhance vaginal breech delivery simulation sessions was also implemented in November 2014. The session was updated to teach the practice of upright breech deliveries. The session continues to run once every two weeks and there is a requirement for all clinical staff to attend the session on an annual basis, compliance with which is subject to audit.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 3 · response
Published 23 March 2016

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

Participate in the Regional Maternity Patient Safety Network and disseminate lessons learned regionally.

Verbatim wording from the response

“In addition to local learning, the inquest would also have heard that the Trust is taking an integral part in the newly-developed Regional Maternity Patient Safety Network. The principles are set out in the statement of ████████ at paragraph 48. Had oral evidence been heard, she would have added that the Network is now established, the first meeting having taken place in November 2015. This case is on the agenda for discussion on the forthcoming Network meeting on 24 May, where lessons learned will be disseminated on a regional level.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 2 · response
Published 23 March 2016

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

National admission-scanning policy cannot be implemented without sufficient equipment, training and competency-maintenance resources across the NHS.

Verbatim wording from the response

“As you would have heard from ████████ nationally, 30% of breech presentations are undiagnosed when the mother arrives at hospital in labour. This is because a breech presentation is inherently difficult to diagnose on palpation. As referred to at paragraph 4 of ████████ statement, scanning of women on admission to maternity units is not within national guidelines. There are not enough resources on a national level to implement such a policy. Resource issues not only include the availability of equipment but also the training and competency maintenance of staff to carry out and interpret the imaging. The Trust position remains that any changes on a”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 3 · response
Published 23 March 2016

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

NICE or the Department of Health must consider and address national scanning-policy changes because of their NHS-wide resource implications.

Verbatim wording from the response

“national level in the policies around the scanning of women on arrival at maternity units would need to be considered and addressed by NICE or the Department of Health due to the resource implications that it would have for the NHS as a whole. For the avoidance of doubt, the steps taken by the Trust far in advance of the Regulation 28 report, which go beyond national practice and expected standards, has only been possible because of significant funding secured from the Department of Health's capital fund for the prevention of avoidable harm in maternity care.”

Source location

2016-0118-Response-by-South-Tees-Hospitals
Page 4 · response
Published 23 March 2016

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