PFD report

Finley Austin May · Prevention of Future Deaths report

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Issued 26 Jul 2023•East Riding and Hull

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

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 raised4

  1. Lack of training guidance for Keilland’s forceps use
  2. Lack of guidance on the minimum annual case volume needed to maintain Keilland’s forceps skills
  3. Lack of clear guidance on alternative management of malrotation and asynclitism after abandonment of Keilland’s forceps
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

    Update the Assisted Vaginal Birth guidance after the ROTATE research project concludes.

    Stated by Royal College of Obstetricians and GynaecologistsStated plannedThe respondent said that this action was planned when they made their response on 4 August 2023.
  2. Action

    Add a safety statement to the Kielland’s forceps guidance webpage promoting safe use and experienced supervision.

    Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.

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

  1. Position

    The College does not recommend a minimum annual number of Kielland’s forceps cases because training and competence are assessed on a competency-based basis.

    Stated by Royal College of Obstetricians and GynaecologistsNo 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

Lack of training guidance for Keilland’s forceps use

Wider context from the report

“(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them. (2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice. (3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby. (4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training. (5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism. ”

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

Lack of guidance on the minimum annual case volume needed to maintain Keilland’s forceps skills

Wider context from the report

“(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them. (2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice. (3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby. (4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training. (5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism. ”

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

Lack of clear guidance on alternative management of malrotation and asynclitism after abandonment of Keilland’s forceps

Wider context from the report

“(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them. (2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice. (3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby. (4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training. (5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism. ”

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

Insufficient awareness of complications associated with Keilland’s forceps

Wider context from the report

“(1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them. (2) Evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and this is a well-accepted practice. (3) Evidence was heard that such malpositions can be corrected manually, or by the use of the Ventouse suction apparatus, but the evidence adduced was that these alternative techniques may be inferior to the use of Keilland’s forceps in skilled and practiced hands; this might mean increased risk to both mother and baby. (4) Continued use of Keilland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training. (5) If NHS trusts have abandoned the use of Keilland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism. ”

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

Update the Assisted Vaginal Birth guidance after the ROTATE research project concludes.

Verbatim wording from the response

“RCOG Green-top Guideline No. 26 on Assisted Vaginal Birth, published in 2020, provides the evidence-based recommendations to support practitioners around use of instruments for assisted vaginal births, and promotes support for the availability of intrapartum ultrasonography for clinicians in their daily practice.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 4 August 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

Add a safety statement to the Kielland’s forceps guidance webpage promoting safe use and experienced supervision.

Verbatim wording from the response

“any such serious injury is taken very seriously by the RCOG. We added a safety statement in relation to use of Kielland’s forceps to our guidance on the webpage in June 2023, which states the following:”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 4 August 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

The College does not recommend a minimum annual number of Kielland’s forceps cases because training and competence are assessed on a competency-based basis.

Verbatim wording from the response

“(4) Continued use of Kielland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 1 · response
Published 4 August 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

    Work collaboratively with stakeholders, including coroners, to improve the standard of care for women.

    Stated by Royal College of Obstetricians and GynaecologistsStated plannedThe respondent said that this action was planned when they made their response on 4 August 2023.
  2. 2

    Communicate the updated guidance to Integrated Care Boards so all maternity trusts are aware of it.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 4 August 2023.
  3. 3

    Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.4

  1. 1

    The risk of cervical spine injury from Kielland’s forceps is extremely low.

    Stated by Royal College of Obstetricians and GynaecologistsDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    The Assisted Vaginal Birth guidance will not be updated until nationally funded research on rotational birth has concluded.

    Stated by Royal College of Obstetricians and GynaecologistsUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. 3

    Ultrasound assessment is advisable before forceps application but is not mandated before all assisted births under current guidance.

    Stated by Royal College of Obstetricians and GynaecologistsExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  4. 4

    Kielland’s forceps remain appropriate in certain clinical situations, rather than being inherently unsuitable for assisted vaginal delivery.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Work collaboratively with stakeholders, including coroners, to improve the standard of care for women.

Verbatim wording from the response

“The RCOG is committed to improving the standard of care provided for women by working collaboratively with all stakeholders, including Coroners.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 4 August 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

Communicate the updated guidance to Integrated Care Boards so all maternity trusts are aware of it.

Verbatim wording from the response

“NHS England’s regional members of the Regulation 28 Working Group (please see penultimate paragraph) will be asked to communicate with their Integrated Care Boards to ensure that all Trusts are fully aware of the updated guidance.”

Source location

Response from NHS England
Page 2 · response
Published 4 August 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

Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

Verbatim wording from the response

“I would like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 4 August 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

The risk of cervical spine injury from Kielland’s forceps is extremely low.

Verbatim wording from the response

“(5) If NHS trusts have abandoned the use of Kielland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 2 · response
Published 4 August 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

The Assisted Vaginal Birth guidance will not be updated until nationally funded research on rotational birth has concluded.

Verbatim wording from the response

“RCOG Green-top Guideline No. 26 on Assisted Vaginal Birth, published in 2020, provides the evidence-based recommendations to support practitioners around use of instruments for assisted vaginal births, and promotes support for the availability of intrapartum ultrasonography for clinicians in their daily practice.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 4 August 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

Ultrasound assessment is advisable before forceps application but is not mandated before all assisted births under current guidance.

Verbatim wording from the response

“Rotational births using Kielland’s forceps should only be performed by experienced operators or under the direct supervision of an experienced operator. The operator is required to define fetal head position and identify the position of the occiput correctly, in order to safely undertake a rotational birth. In this regard, an ultrasound assessment of the fetal head position prior to application of forceps is more reliable than clinical examination and is advisable.”

Source location

Response from Royal College of Obstetricians and Gynaecologists
Page 3 · response
Published 4 August 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

Kielland’s forceps remain appropriate in certain clinical situations, rather than being inherently unsuitable for assisted vaginal delivery.

Verbatim wording from the response

“Your Report raised that the use of Kielland’s rotational forceps resulted in high spinal cord injury leading to the death of Finley. During the course of the inquest, evidence was heard that the use of these obstetric forceps can facilitate delivery from the mid-pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or occipito-posterior, and that this is a well-accepted practice.”

Source location

Response from NHS England
Page 1 · response
Published 4 August 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