PFD report

Thomas Beaty · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 31 Mar 2015•Manchester North

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
4

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

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.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Difficulty for Trusts to change guidance without external guidance improvement
    Part of recurring concern: Unsafe updating of clinical policies and guidance
  2. Use of misleading and clinically inappropriate ‘gentle’ traction terminology
    Part of recurring concern: Unreliable terminology in obstetric delivery guidance and decisions
  3. Lack of operational definitions for instrumental-delivery terminology
    Part of recurring concern: Unreliable terminology in obstetric delivery guidance and decisions
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.4

  1. Action

    Issue the consultant-presence requirement for all instrumental delivery trials and audit compliance across both inpatient sites.

    Stated by The Pennine Acute HospitalsStated completedThe respondent said that this action was complete when they made their response on 31 March 2015.
  2. Action

    Review the Trust guideline again after receiving the RCOG recommendations.

    Stated by The Pennine Acute HospitalsStated plannedThe respondent said that this action was planned when they made their response on 31 March 2015.
  3. Action

    Revise and ratify the assisted vaginal delivery guideline with clarified consultant presence, abandonment criteria, terminology and traction requirements.

    Stated by The Pennine Acute HospitalsStated in progressThe respondent said that this action was in progress when they made their response on 31 March 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    RCOG is responsible for addressing concerns about its professional guidance.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Difficulty for Trusts to change guidance without external guidance improvement

Wider context from the report

“1. Instrumental Delivery – the Court heard how local/national protocols and training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘…When to abandon the procedure: • No evidence of progressive descent with each pull • No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator…’ The first point by implication must mean that where there is no descent with the first pull, then the procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction. 2. Terminology - The RCOG Guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery. 3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with. 4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the Guidance issued by the RCOG. ”

Is this part of a recurring concern?

Yes — Unsafe updating of clinical policies and guidance.

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

Use of misleading and clinically inappropriate ‘gentle’ traction terminology

Wider context from the report

“1. Instrumental Delivery – the Court heard how local/national protocols and training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘…When to abandon the procedure: • No evidence of progressive descent with each pull • No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator…’ The first point by implication must mean that where there is no descent with the first pull, then the procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction. 2. Terminology - The RCOG Guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery. 3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with. 4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the Guidance issued by the RCOG. ”

Is this part of a recurring concern?

Yes — Unreliable terminology in obstetric delivery guidance and decisions.

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 operational definitions for instrumental-delivery terminology

Wider context from the report

“1. Instrumental Delivery – the Court heard how local/national protocols and training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘…When to abandon the procedure: • No evidence of progressive descent with each pull • No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator…’ The first point by implication must mean that where there is no descent with the first pull, then the procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction. 2. Terminology - The RCOG Guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery. 3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with. 4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the Guidance issued by the RCOG. ”

Is this part of a recurring concern?

Yes — Unreliable terminology in obstetric delivery guidance and decisions.

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

Ambiguity in guidance on when to abandon instrumental delivery

Wider context from the report

“1. Instrumental Delivery – the Court heard how local/national protocols and training programmes are routinely based on guidance issued by the Royal College of Obstetricians and NICE. The guidance in use at the time of Thomas’ birth was found to be ambiguous, misleading and potentially open to misinterpretation. A key example was: ‘…When to abandon the procedure: • No evidence of progressive descent with each pull • No evidence of imminent birth following 3 pulls of a correctly placed instrument by an experienced operator…’ The first point by implication must mean that where there is no descent with the first pull, then the procedure ought to be abandoned, yet the second point suggests abandonment after a 3rd traction. 2. Terminology - The RCOG Guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’. This was particularly important in Thomas’ case, as it had a bearing on the decision making processes applied during the course of the forceps delivery. 3. Traction - The term ‘gentle’ (traction) forming the ‘G’ of the algorithm within the Trust’s protocol was misleading and not in line with the RCOG Guidance. The clinical evidence suggested that in most (if not all) cases mild to moderate traction is routinely applied by clinicians in order to ensure safe and successful instrumental delivery. Whilst it was accepted that this was often subjective, the term ‘gentle’ was clinically out with. 4. Development of Trust Guidance – it is difficult for Trusts to change their guidance until and unless there is a change/material improvement in the Guidance issued by the RCOG. ”

Is this part of a recurring concern?

Yes — Unreliable terminology in obstetric delivery guidance and decisions.

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

Issue the consultant-presence requirement for all instrumental delivery trials and audit compliance across both inpatient sites.

Verbatim wording from the response

“Immediately following the inquest a directive was issued to the obstetric medical team highlighting the requirement for a Consultant Obstetrician to be present in theatre for all trials of instrumental deliveries regardless of the level of experience of the Middle Grade operator. The guideline was amended to reflect this requirement and an audit undertaken on both inpatient sites in April to provide assurance that this requirement was being met consistently. Upon receipt of the concerns you raised in the Regulation 28 Report to Prevent Future Deaths the guideline has been reviewed and revised further in order to address the areas that were considered ambiguous, misleading and potentially open to misinterpretation.”

Source location

2015-0130-Response-by-Pennine-Acute-Hospitals
Page 1 · response
Published 31 March 2015

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

Review the Trust guideline again after receiving the RCOG recommendations.

Verbatim wording from the response

“4. Development of Trust Guidance We have made the interim changes to the Trust guideline whilst waiting for the RCOG to respond to the recommendations. However we will review again once the RCOG recommendations have been received.”

Source location

2015-0130-Response-by-Pennine-Acute-Hospitals
Page 2 · response
Published 31 March 2015

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

Revise and ratify the assisted vaginal delivery guideline with clarified consultant presence, abandonment criteria, terminology and traction requirements.

Verbatim wording from the response

“Instrumental Delivery Guidance Since the sad death of Thomas Beaty, the Trust reviewed and revised the Guideline for Assisted Vaginal Delivery in order to provide staff with greater clarity and guidance regarding the requirement for Consultant presence for trial in theatre if the operator is less than 5ft 6. Additional guidance was also added with regards to the flexion point, complications of instrumental deliveries, and disimpaction of the head. This guideline was ratified in December 2014.”

Source location

2015-0130-Response-by-Pennine-Acute-Hospitals
Page 1 · response
Published 31 March 2015

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 the coroner’s report to the RCOG to communicate the concerns about ambiguity in its maternity guidance.

Verbatim wording from the response

“You had a number of concerns about the guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG), which the inquest found to be ambiguous, misleading and potentially open to misinterpretation, giving as the example that the RCOG guidance did not provide operational definitions for words such as ‘imminent’ (vis a vis birth) or ‘crowning’.”

Source location

2015-0130-Response-by-Department-of-Health
Page 1 · response
Published 31 March 2015

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

RCOG is responsible for addressing concerns about its professional guidance.

Verbatim wording from the response

“While local maternity and neonatal care providers must determine how best to deliver services in their area, in doing so we would expect them to give due regard to RCOG and other professional guidance. To this end, a copy of your report has been sent to the RCOG to make them aware of the concerns you have raised and I understand that they have responded to you directly.”

Source location

2015-0130-Response-by-Department-of-Health
Page 1 · response
Published 31 March 2015

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

Local maternity and neonatal providers are responsible for determining how services should be delivered in their areas.

Verbatim wording from the response

“While local maternity and neonatal care providers must determine how best to deliver services in their area, in doing so we would expect them to give due regard to RCOG and other professional guidance. To this end, a copy of your report has been sent to the RCOG to make them aware of the concerns you have raised and I understand that they have responded to you directly.”

Source location

2015-0130-Response-by-Department-of-Health
Page 1 · response
Published 31 March 2015

Open published response
Back to top

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