Louisa Walker · Prevention of Future Deaths report

I conducted an inquest into the death of Louisa Walker which concluded on 23rd of October 2025. I recorded a narrative conclusion as follows:
Louisa’s death was the direct result of a resident doctor performing a manoeuvre to try to disimpact her head during a caesarean section, which caused skull fractures and intracranial haemorrhage.

Louisa’s head was noted to be impacted in her mother’s pelvis during a caesarean section. She suffered skull fractures and intracranial bleeding as a result of the manoeuvres used to disimpact her head. She was born on 25th May 2024, and died on 28th June 2024.

The trust’s own investigation action plan highlighted a need for training around impacted fetal head scenarios, following the tragic death of Louisa.

The trust served a statement from a senior patient safety lead for the maternity department which stated:
"Our department has taken this matter very seriously and is committed to learning and changing our practice to avoid recurrence of a similar incident."

At the time of the inquest, it was almost 18 months since Louisa’s birth and death. The trust was aware that evidence would be required at the inquest regarding their action plan, and that this evidence would be given not just to the coroner, but in the presence of Louisa’s parents. Despite this, we heard in evidence that only 17% of obstetricians have undergone this further training. I understand the training is around 30-60 minutes in duration.

1. If the trust is taking this matter very seriously and is committed to learning, I am concerned that 83% of their obstetricians have not undergone this training. For the avoidance of doubt, the training referred to is training arising out of this incident, and not standard obstetric training on this issue, provided before Louisa’s death.