PFD report

Frances Olwyn Coppaccini · Prevention of Future Deaths report

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Issued 27 Jan 2017•Kent (North-West)

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.

View original report
Concerns
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
14

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 raised6

  1. Delays in requesting urgent help from an intensivist or anaesthetist
  2. Failure to provide staff grade anaesthetists and supervisors with the respective identities of the parties involved
    Part of recurring concern: Failure to reliably communicate clinicians’ identities and clinical grades
  3. Failure to check that no part of the placenta remains following caesarean section delivery
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.9

  1. Action

    Review documentation requirements and conduct regular local and national clinical documentation audits.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
  2. Action

    Deliver mandatory annual multidisciplinary PROMPT training, including emergency drills, communication, escalation, teamwork and updated policy guidance.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  3. Action

    Provide annual theoretical and practical training for Obstetricians and Midwives to strengthen caesarean-section and haemorrhage management.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

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

Delays in requesting urgent help from an intensivist or anaesthetist

Wider context from the report

“4. What steps have been taken to avoid there being delays in a request for urgent help for an intensivist/anaesthetist. ”

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 to provide staff grade anaesthetists and supervisors with the respective identities of the parties involved

Wider context from the report

“3. Supervision – What action has been taken to ensure that staff grade anaesthetists are supervised and that both the staff grade and supervisor are provided details of the respective identities of the parties involved. ”

Is this part of a recurring concern?

Yes — Failure to reliably communicate clinicians’ identities and clinical grades.

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 to check that no part of the placenta remains following caesarean section delivery

Wider context from the report

“1. What action is taken to check and ensure no part of the placenta remains following a caesarean section delivery? ”

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

Inadequate clinical note keeping at the hospital

Wider context from the report

“5. The Inquest showed a number of examples of inadequate note keeping at the hospital – what actions have been taken to ensure this is not repeated in the future. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 to follow the protocol for management of postpartum haemorrhage

Wider context from the report

“2. The protocol for the management of post partum haemorrhage was not followed by the medical staff. What procedures have been instigated to avoid this happening 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

Failure to supervise staff grade anaesthetists

Wider context from the report

“3. Supervision – What action has been taken to ensure that staff grade anaesthetists are supervised and that both the staff grade and supervisor are provided details of the respective identities of the parties involved. ”

Is this part of a recurring concern?

Yes — Failure to supervise clinicians during clinical work.

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

Review documentation requirements and conduct regular local and national clinical documentation audits.

Verbatim wording from the response

“We continually review the documentation to be completed in addition to noting in the healthcare records, to ensure they are easy to use in the highly-pressurised situations in which our staff work.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 5 · response
Published 19 February 2017

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 mandatory annual multidisciplinary PROMPT training, including emergency drills, communication, escalation, teamwork and updated policy guidance.

Verbatim wording from the response

“The PROMPT method of training (Practical Obstetric Multi-Professional Training), which is a training programme run in maternity units across the country, incorporates the management of a range of Obstetric emergency situations with interactive drills and workshops to provide 'hands on' experience of practical skills and decision-making. The components of team working, including training for communication in an emergency, feature throughout the course. In the training sessions, which are attended by multidisciplinary groups of staff, each member of staff plays the role in the training scenario that they would play in a real situation.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 2 · response
Published 19 February 2017

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

Provide annual theoretical and practical training for Obstetricians and Midwives to strengthen caesarean-section and haemorrhage management.

Verbatim wording from the response

“We acknowledge, with regret, that this process was not successfully followed in Mrs Cappuccini’s case, however in the intervening years since this tragic incident all of our Obstetricians and Midwives have completed several rounds of annual training (theoretical and practical) to ensure that they are as qualified and experienced as possible to ensure better outcomes in the future.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 2 · response
Published 19 February 2017

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

Provide dedicated consultant anaesthetist cover for elective caesarean sections, leaving the Delivery Suite consultant available for emergencies.

Verbatim wording from the response

“4) What steps have been taken to avoid there being delays in a request for urgent help for an intensivist/anaesthetist.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 4 · response
Published 19 February 2017

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

Require staff caring for patients at risk of postpartum haemorrhage to read the protocol and record compliance.

Verbatim wording from the response

“2) The protocol for the management of post-partum haemorrhage was not followed by the medical staff. What procedures have been instigated to avoid this happening again.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 2 · response
Published 19 February 2017

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 electronic rota and induction arrangements identifying anaesthetic supervision, consultants and emergency contact routes for staff-grade, trainee and locum anaesthetists.

Verbatim wording from the response

“All Anaesthetists have an electronic rota app on their phones and can identify who is the staff grade on for Labour Ward and who is the consultant covering.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 4 · response
Published 19 February 2017

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

Provide documentation training through annual departmental training, mandatory Information Governance training, legal updates and clinical leadership programmes.

Verbatim wording from the response

“Documentation training underpins core training for nurses, doctors and allied health practitioners at all levels within the organisation. All staff are aware of the importance of clear, and contemporaneous record keeping and the balance that must be struck between this obligation and the immediate care and treatment to be provided to our patients.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 5 · response
Published 19 February 2017

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

Audit postpartum-haemorrhage documentation annually and review the proforma, including its new theatre fluid-input and output section.

Verbatim wording from the response

“We are always seeking to improve our service and minimise patient harm, and to that end we constantly review our processes, training and documentation. In light of the potential issues regarding drug use in PPH cases, our Pharmacy team have created a new guidance document for staff (copy enclosed). The Obstetric department is also reviewing fluid replacement at PPH, and undertakes yearly audits regarding PPH documentation including the regular review of the PPH Proforma to ensure it meets the needs of staff in the time critical situations they work in. The latest version of the PPH Proforma, which includes a new section for recording fluid input and output in theatre, is enclosed for your information.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 3 · response
Published 19 February 2017

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

Maintain and distribute real-time, paper, whiteboard and weekly emailed anaesthetic rotas with direct contact details and hospital-specific terminology.

Verbatim wording from the response

“The Anaesthetic and Obstetric departments, as well as switchboard, have access to a real-time electronic rota for the Anaesthetic department. There is also a weekly paper rota kept on Delivery Suite, and consultants add their name and bleep number to the whiteboard in the Labour Ward handover room. Additionally, the rotas are emailed out weekly to all senior staff and Delivery Suite Band 7 Midwives.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 4 · response
Published 19 February 2017

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.5

  1. 1

    Review fluid replacement practice in postpartum haemorrhage cases.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
  2. 2

    Disseminate learning from Mrs Cappuccini’s case through a joint Obstetric and Anaesthetic Clinical Governance session.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  3. 3

    Issue new pharmacy guidance addressing potential drug-use issues in postpartum haemorrhage cases.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  4. 4

    Provide high-fidelity simulation training and live emergency drills for relevant maternity staff.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  5. 5

    Share learning from the recent good-practice case through a report circulated internally and externally.

    Stated by Maidstone and Tunbridge Wells NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.

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 fluid replacement practice in postpartum haemorrhage cases.

Verbatim wording from the response

“We are always seeking to improve our service and minimise patient harm, and to that end we constantly review our processes, training and documentation. In light of the potential issues regarding drug use in PPH cases, our Pharmacy team have created a new guidance document for staff (copy enclosed). The Obstetric department is also reviewing fluid replacement at PPH, and undertakes yearly audits regarding PPH documentation including the regular review of the PPH Proforma to ensure it meets the needs of staff in the time critical situations they work in. The latest version of the PPH Proforma, which includes a new section for recording fluid input and output in theatre, is enclosed for your information.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 3 · response
Published 19 February 2017

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

Disseminate learning from Mrs Cappuccini’s case through a joint Obstetric and Anaesthetic Clinical Governance session.

Verbatim wording from the response

“On 22 March 2017 we also ran a joint Clinical Governance session with Obstetrics and Anaesthesia and Mrs Cappuccini’s case (including inquest outcome and department reflections) was presented to a cross-section of staff – Consultants, Junior Doctors, Nurses, Midwives and Operating Theatre Practitioners. The session was well received and promoted much discussion and reflection, with suggestions for best practice shared across the two Directorates.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 3 · response
Published 19 February 2017

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

Issue new pharmacy guidance addressing potential drug-use issues in postpartum haemorrhage cases.

Verbatim wording from the response

“We are always seeking to improve our service and minimise patient harm, and to that end we constantly review our processes, training and documentation. In light of the potential issues regarding drug use in PPH cases, our Pharmacy team have created a new guidance document for staff (copy enclosed). The Obstetric department is also reviewing fluid replacement at PPH, and undertakes yearly audits regarding PPH documentation including the regular review of the PPH Proforma to ensure it meets the needs of staff in the time critical situations they work in. The latest version of the PPH Proforma, which includes a new section for recording fluid input and output in theatre, is enclosed for your information.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 3 · response
Published 19 February 2017

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

Provide high-fidelity simulation training and live emergency drills for relevant maternity staff.

Verbatim wording from the response

“In addition to the PROMPT training, the Trust also offers high fidelity simulation training for Obstetricians, Midwives and Operating Theatre Practitioners, and live emergency drills are run on the Delivery Suite when acuity allows. An example of this training is enclosed.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 3 · response
Published 19 February 2017

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

Share learning from the recent good-practice case through a report circulated internally and externally.

Verbatim wording from the response

“Post-Partum haemorrhage (PPH) is a common occurrence in child birth, however due to the robustness of our processes and the additional training and support provided to staff, our outcomes are positive. Just three-weeks ago in our weekly Trust-wide newsletter I was able to praise the hard work of the entire team involved in providing care to a woman in our care who ultimately saved her life. The woman had suffered significant PPH after the caesarean section delivery of her baby but the volumes of blood loss were higher and over a more prolonged period that would be expected. The professionalism of the whole team involved in her care – from administrators, Porters, Haematology, Anaesthetics, Neonatal, Theatres, ITU, Obstetricians and Midwifery - meant that both mother and baby were stabilised and discharged home.”

Source location

2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 2 · response
Published 19 February 2017

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