PFD report

Elliott James Harratt · Prevention of Future Deaths report

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Issued 20 Jul 2023•Manchester South

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

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 raised2

  1. Failure to clearly communicate sensitising events and the required Anti-D action
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and familiesPart of recurring concern: Inadequate safety-netting advice for patients and carers
  2. Lack of clear, accessible signposting of events requiring a call to maternity triage
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.1

  1. Action

    Highlight the importance of giving RhD-positive mothers appropriate guidance, written information and advice on when to contact services.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 28 July 2023.

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

  1. Position

    Existing written, verbal and online advice consistently tells mothers when to contact maternity services, despite differing Trust arrangements.

    Stated by NHS Greater Manchester Integrated Care BoardExisting 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 clearly communicate sensitising events and the required Anti-D action

Wider context from the report

“The inquest heard evidence that the rhesus status of Elliott’s mum meant that after a sensitising event Anti D needed to be given to prevent Rhesus disease in a newborn baby. The evidence before the inquest was that the type of events that would constitute a sensitising event and what action was then required were not made clear to Elliott’s mum. In addition, the type of events where a call to maternity triage for advice were not made clear to his mum. This was, the evidence suggested, because there was no readily accessible or consistent list given to expectant mothers at booking in appointments or at follow up signposting them. Such a document in the form of a handout laminate or as a list in the handheld notes would increase awareness of events where a call to maternity triage would be advisable for health of both the mother and baby enabling health professionals to intervene at the earliest possible stage. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families; Inadequate safety-netting advice for patients and carers.

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

Lack of clear, accessible signposting of events requiring a call to maternity triage

Wider context from the report

“The inquest heard evidence that the rhesus status of Elliott’s mum meant that after a sensitising event Anti D needed to be given to prevent Rhesus disease in a newborn baby. The evidence before the inquest was that the type of events that would constitute a sensitising event and what action was then required were not made clear to Elliott’s mum. In addition, the type of events where a call to maternity triage for advice were not made clear to his mum. This was, the evidence suggested, because there was no readily accessible or consistent list given to expectant mothers at booking in appointments or at follow up signposting them. Such a document in the form of a handout laminate or as a list in the handheld notes would increase awareness of events where a call to maternity triage would be advisable for health of both the mother and baby enabling health professionals to intervene at the earliest possible stage. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Highlight the importance of giving RhD-positive mothers appropriate guidance, written information and advice on when to contact services.

Verbatim wording from the response

“We will use this event as an opportunity to highlight the importance of ensuring that mothers who do have a D blood type, have the appropriate guidance, written information and understand when to contact services.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 28 July 2023

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 written, verbal and online advice consistently tells mothers when to contact maternity services, despite differing Trust arrangements.

Verbatim wording from the response

“Each of our Trusts in Greater Manchester that provide maternity services are set up slightly differently in relation to how they deliver services, however the advice they provide to mothers on when to contact services is consistent across the system and comes in many forms, written, verbal and online.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 28 July 2023

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.3

  1. 1

    Monitor key learning points and recommendations to ensure they become embedded in practice.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 28 July 2023.
  2. 2

    Cascade learning from this and similar cases through Greater Manchester and borough governance and learning forums, including discussion at the maternity and neonatal safety panel.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 28 July 2023.
  3. 3

    Present and share learning from the case with the Greater Manchester System Quality Group.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 28 July 2023.

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

Monitor key learning points and recommendations to ensure they become embedded in practice.

Verbatim wording from the response

“In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 28 July 2023

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

Cascade learning from this and similar cases through Greater Manchester and borough governance and learning forums, including discussion at the maternity and neonatal safety panel.

Verbatim wording from the response

“2. As part of our approach to embedding the learning we share the learning from this and similar cases at Greater Manchester and borough level. This is cascaded to professionals through relevant governance and learning forums to ensure that learning is incorporated into their services. In this case it will be discussed at the Local Maternity and Neonatal Network Safety Assurance Panel on the 5th of October 2023.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 28 July 2023

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

Present and share learning from the case with the Greater Manchester System Quality Group.

Verbatim wording from the response

“1. Learning to be presented/shared with the Greater Manchester System Quality Group on the 16th of November 2023. This meeting is attended by a broad range of system leaders including clinical and care leaders, commissioners of specialist services, locality representatives from each of the 10 GM boroughs, the CQC, Healthwatch who represent the public voice and NICE. Through sharing in this forum, we expect members to review and ensure learning is incorporated into their commissioning services.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 28 July 2023

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