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 dismpact her head. She was born on 25th May 2024, and died on 28th June 2024.

References were made throughout the inquest to the fact that there is no green top guideline for this obstetric emergency.

I understand that the RCOG scientific impact paper number 73 has been retracted (for largely unrelated reasons). The algorithm referred to in that paper had been adopted by the trust in this case – and that may perhaps be the case in other hospitals – but there is currently no national guidance on dealing with impacted fetal head.

1. There is no national guidance (by way of green top guideline or otherwise) dealing with impacted fetal head seen at caesarean section.
2. Whilst the algorithm referred to in RCOG scientific impact paper number 73 may well have been adopted by many trusts, there is a risk of uncertainty and absence of relevant training in respect of this obstetric emergency.
3. I understand that impacted fetal head is becoming increasingly common.