PFD report

Angus Jonathan Labofski WEST · Prevention of Future Deaths report

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Issued 20 Apr 2016•West Yorkshire Eastern

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
2

Of 1 recipient

Stated actions
4

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 retain the placenta and all its appendages for pathological examination when a newborn is deteriorating and may die
    Part of recurring concern: Unreliable retention of biological samples for postmortem investigation
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.2

  1. Action

    Retain placentas for poor-condition, extremely preterm or deteriorating babies locally for 30 days, then send them to Leeds for histopathology if the baby dies, subject to consent.

    Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 April 2016.
  2. Action

    Implement 24-hour retention of live-birth placentas through bagging, labelling, dating and refrigerated or labour-ward storage, followed by permitted disposal when conditions are satisfactory.

    Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 April 2016.

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

  1. Position

    The Trust considers that its undertakings constitute all reasonable steps needed to prevent a similar occurrence.

    Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustNo action considered necessaryThe respondent said that 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 retain the placenta and all its appendages for pathological examination when a newborn is deteriorating and may die

Wider context from the report

“(1) After the baby was born the placenta was not retained. Within a short time after his birth he became unwell and despite all efforts his death was confirmed. It was likely that a post mortem examination would be needed to determine the cause of death. It would have been of assistance to the Pathologist to be able to examine the placenta to show the possibility of a toxoplasmosis infection; to establish if relevant the possibility of placental abruption and to establish if the umbilical cord was kinked, trapped or in any way damaged which could have caused or contributed to the death. I therefore recommend and request that when it is foreseeable that at birth or shortly thereafter, the baby’s condition is poor and is deteriorating which may lead to death, then the placenta and all its appendages should be retained and be made available to the Pathologist for further examination. ”

Is this part of a recurring concern?

Yes — Unreliable retention of biological samples for postmortem investigation.

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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

Retain placentas for poor-condition, extremely preterm or deteriorating babies locally for 30 days, then send them to Leeds for histopathology if the baby dies, subject to consent.

Verbatim wording from the response

“As a consequence of the tragic outcome in this case and the inquest findings we undertake to institute the following standard operating procedure in respect to retention of placenta following childbirth. Points a) and b) are current standard practice and the remaining points are to be instituted by September 1st 2016.”

Source location

2016-0158-Response-by-York-Teaching-Hospital
Page 1 · response
Published 20 April 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

Implement 24-hour retention of live-birth placentas through bagging, labelling, dating and refrigerated or labour-ward storage, followed by permitted disposal when conditions are satisfactory.

Verbatim wording from the response

“As a consequence of the tragic outcome in this case and the inquest findings we undertake to institute the following standard operating procedure in respect to retention of placenta following childbirth. Points a) and b) are current standard practice and the remaining points are to be instituted by September 1st 2016.”

Source location

2016-0158-Response-by-York-Teaching-Hospital
Page 1 · response
Published 20 April 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

The Trust considers that its undertakings constitute all reasonable steps needed to prevent a similar occurrence.

Verbatim wording from the response

“I hope that this undertaking alleviates the concerns raised during the recent inquest and reassures you that all reasonable steps have been taken to prevent a similar occurrence in the future. I would be happy to write to you again after the proposed implementation date to confirm that the Trust has complied with these undertakings.”

Source location

2016-0158-Response-by-York-Teaching-Hospital
Page 2 · response
Published 20 April 2016

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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

    Routinely inspect the placenta and all appendices at every delivery.

    Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 April 2016.
  2. 2

    Send placentas from stillborn infants or intrapartum deaths for detailed histopathology examination, with parental consent.

    Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 April 2016.

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

Routinely inspect the placenta and all appendices at every delivery.

Verbatim wording from the response

“As a consequence of the tragic outcome in this case and the inquest findings we undertake to institute the following standard operating procedure in respect to retention of placenta following childbirth. Points a) and b) are current standard practice and the remaining points are to be instituted by September 1st 2016.”

Source location

2016-0158-Response-by-York-Teaching-Hospital
Page 1 · response
Published 20 April 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

Send placentas from stillborn infants or intrapartum deaths for detailed histopathology examination, with parental consent.

Verbatim wording from the response

“As a consequence of the tragic outcome in this case and the inquest findings we undertake to institute the following standard operating procedure in respect to retention of placenta following childbirth. Points a) and b) are current standard practice and the remaining points are to be instituted by September 1st 2016.”

Source location

2016-0158-Response-by-York-Teaching-Hospital
Page 1 · response
Published 20 April 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