PFD report

Raphael Maximilian Kolbe · Prevention of Future Deaths report

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Issued 8 Apr 2021•West London

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised3

  1. Failure to ensure fetal monitoring requirements during epidural siting are highlighted and followed
    Part of recurring concern: Failure to provide fetal monitoring when clinically required
  2. Failure of hospital policy and practice to clarify attending personnel roles during epidural siting
    Part of recurring concern: Unsafe updating of clinical policies and guidance
  3. Lack of clear hospital guidance for regular review by another midwife or obstetrician
    Part of recurring concern: Failure to provide timely and reliable fresh-eyes reviews in maternity care
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.6

  1. Action

    Disseminate the clarified responsibilities through team meetings, multidisciplinary circulation and skills-and-drills training.

    Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
  2. Action

    Conduct monthly audits to monitor whether the fetal-monitoring and staffing changes are embedded and identify potential issues.

    Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
  3. Action

    Implement clarified midwifery and anaesthetic responsibilities, including maintaining fetal monitoring and providing backup support during epidural insertion.

    Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.

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

  1. Position

    The hourly fresh-eyes reminder is not a hard stop because this could prevent clinically indicated further monitoring or action.

    Stated by The Portland Hospital for Women and ChildrenUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Failure to ensure fetal monitoring requirements during epidural siting are highlighted and followed

Wider context from the report

“It became apparent during the inquest that although a great deal of positive work, reflection and retraining has taken place and amendments to the Hospital policies and guidelines, the policy does still not reflect practise. This is particularly so in respect of the roles of the primary midwife, the second midwife in support and the anaesthetist when an epidural is being sited. In order for greater clarification and protection of the fetal well being, further consideration should be given to ensure all attending personnel are aware of their role. The requirements for fetal monitoring during this particular procedure should be highlighted and practise should reflect hospital policy. The requirement for “fresh eyes” remains under ongoing consideration to encourage and support regular review from another midwife or obstetrician and the hospital are continuing to work on an Action plan to implement best practise. While this is always an area that remains under review, clear guidance from the hospital would best support the staff and facilitate better outcomes. ”

Is this part of a recurring concern?

Yes — Failure to provide fetal monitoring when clinically required.

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 of hospital policy and practice to clarify attending personnel roles during epidural siting

Wider context from the report

“It became apparent during the inquest that although a great deal of positive work, reflection and retraining has taken place and amendments to the Hospital policies and guidelines, the policy does still not reflect practise. This is particularly so in respect of the roles of the primary midwife, the second midwife in support and the anaesthetist when an epidural is being sited. In order for greater clarification and protection of the fetal well being, further consideration should be given to ensure all attending personnel are aware of their role. The requirements for fetal monitoring during this particular procedure should be highlighted and practise should reflect hospital policy. The requirement for “fresh eyes” remains under ongoing consideration to encourage and support regular review from another midwife or obstetrician and the hospital are continuing to work on an Action plan to implement best practise. While this is always an area that remains under review, clear guidance from the hospital would best support the staff and facilitate better outcomes. ”

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

Lack of clear hospital guidance for regular review by another midwife or obstetrician

Wider context from the report

“It became apparent during the inquest that although a great deal of positive work, reflection and retraining has taken place and amendments to the Hospital policies and guidelines, the policy does still not reflect practise. This is particularly so in respect of the roles of the primary midwife, the second midwife in support and the anaesthetist when an epidural is being sited. In order for greater clarification and protection of the fetal well being, further consideration should be given to ensure all attending personnel are aware of their role. The requirements for fetal monitoring during this particular procedure should be highlighted and practise should reflect hospital policy. The requirement for “fresh eyes” remains under ongoing consideration to encourage and support regular review from another midwife or obstetrician and the hospital are continuing to work on an Action plan to implement best practise. While this is always an area that remains under review, clear guidance from the hospital would best support the staff and facilitate better outcomes. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and reliable fresh-eyes reviews in maternity care.

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

Disseminate the clarified responsibilities through team meetings, multidisciplinary circulation and skills-and-drills training.

Verbatim wording from the response

“These clarifications have also been discussed in team meetings, circulated amongst the midwifery multi-disciplinary team (which includes the anaesthetists) and used in the training programme ‘skills and drills’.”

Source location

2021-0029-Response-from-The-Portland-Hospital-Redacted
Page 2 · response
Published 9 February 2021

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

Conduct monthly audits to monitor whether the fetal-monitoring and staffing changes are embedded and identify potential issues.

Verbatim wording from the response

“The investigating team created an action plan to address the areas for learning, including the above, and put in place monthly audits to ensure the changes were embedded. These monthly audits can also be used for early identification of any potential issues, and therefore will continue to be an ongoing part of the Hospital’s audit process.”

Source location

2021-0029-Response-from-The-Portland-Hospital-Redacted
Page 1 · response
Published 9 February 2021

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

Implement clarified midwifery and anaesthetic responsibilities, including maintaining fetal monitoring and providing backup support during epidural insertion.

Verbatim wording from the response

“As a result of the SI investigation, a number of changes were put in place. In relation to the matters referred to above, it was reiterated to all staff that the primary responsibility of the midwife was in relation to the baby’s fetal monitoring, and that if this could not be maintained whilst assisting the anaesthetist, then another midwife must support the anaesthetist so that the fetal monitoring is not compromised.”

Source location

2021-0029-Response-from-The-Portland-Hospital-Redacted
Page 1 · response
Published 9 February 2021

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

Use the K2 electronic-records system’s hourly pop-up reminder to prompt fresh-eyes review of fetal heart traces during CTG monitoring.

Verbatim wording from the response

“The Portland Hospital for Women and Children introduced the K2 electronic records system within maternity a number of years ago, this system is provided by K2 Medical Systems and is used widely throughout the NHS and Independent sector. A function within the K2 system is an hourly pop-up reminder for the midwife to request a ‘fresh eyes’ review of the fetal heart trace when CTG monitoring is taking place. This reminder is not a ‘hard stop’ within the system as it would prevent further action and monitoring of the patient that may be clinically indicated.”

Source location

2021-0029-Response-from-The-Portland-Hospital-Redacted
Page 2 · response
Published 9 February 2021

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

Operate the hourly second-midwife or designated senior-staff ‘fresh eyes’ fetal-monitoring check procedure and review its use through monthly audits.

Verbatim wording from the response

“At the Portland, all maternity patients admitted to the labour ward are allocated a midwife and are cared for on a 1-2-1 basis. The fresh eyes policy at the Portland Hospital is an additional step for a second midwife to carry out the ‘fresh eyes’ check on an hourly basis, the practice is that each midwife will ‘buddy up’ usually with the midwife in the next labour room to undertake the checks. This is agreed with the Labour Co-Ordinator at the beginning of the shift. When the acuity on the ward does not support the above, another midwife, the maternity labour ward co-ordinator / Labour Ward Sister, is contacted to carry out the check.”

Source location

2021-0029-Response-from-The-Portland-Hospital-Redacted
Page 2 · response
Published 9 February 2021

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

Update the Fetal Monitoring and Epidural Analgesia in Labour policies to clarify staff responsibilities during epidural insertion.

Verbatim wording from the response

“Whilst the learning from the SI was properly embedded within the Hospital, we acknowledge that in relation to the ‘budding’ system and the role of the anaesthetist, these changes were not properly reflected in the Portland’s written policy. We apologise for this, and can confirm that this has now been addressed within the following updated policies, attached for your consideration:”

Source location

2021-0029-Response-from-The-Portland-Hospital-Redacted
Page 1 · response
Published 9 February 2021

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 hourly fresh-eyes reminder is not a hard stop because this could prevent clinically indicated further monitoring or action.

Verbatim wording from the response

“The Portland Hospital for Women and Children introduced the K2 electronic records system within maternity a number of years ago, this system is provided by K2 Medical Systems and is used widely throughout the NHS and Independent sector. A function within the K2 system is an hourly pop-up reminder for the midwife to request a ‘fresh eyes’ review of the fetal heart trace when CTG monitoring is taking place. This reminder is not a ‘hard stop’ within the system as it would prevent further action and monitoring of the patient that may be clinically indicated.”

Source location

2021-0029-Response-from-The-Portland-Hospital-Redacted
Page 2 · response
Published 9 February 2021

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 hourly fresh-eyes checks, midwife buddying, coordinator checks, clear policy and monthly audits provide the hospital’s ongoing response.

Verbatim wording from the response

“At the Portland, all maternity patients admitted to the labour ward are allocated a midwife and are cared for on a 1-2-1 basis. The fresh eyes policy at the Portland Hospital is an additional step for a second midwife to carry out the ‘fresh eyes’ check on an hourly basis, the practice is that each midwife will ‘buddy up’ usually with the midwife in the next labour room to undertake the checks. This is agreed with the Labour Co-Ordinator at the beginning of the shift. When the acuity on the ward does not support the above, another midwife, the maternity labour ward co-ordinator / Labour Ward Sister, is contacted to carry out the check.”

Source location

2021-0029-Response-from-The-Portland-Hospital-Redacted
Page 2 · response
Published 9 February 2021

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