Albie Henderson Marlow · Prevention of Future Deaths report

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Issued 26 Jan 2017•Bedfordshire and Luton

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

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 raised1

  1. Failure to respect mothers' requests for Caesarean Section delivery
    Part of recurring concern: Unreliable mode-of-delivery decision-making

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. Luton and Dunstable Hospital NHS Foundation Trust

    Review decision-making around non-elective caesarean sections to ensure appropriate classifications.

  2. Luton and Dunstable Hospital NHS Foundation Trust

    Share learning arising from the serious incident investigation.

  3. Luton and Dunstable Hospital NHS Foundation Trust

    Ensure staff consider alternative delivery techniques earlier when managing an impacted fetal head.

  4. Luton and Dunstable Hospital NHS Foundation Trust

    Consider how to improve the timeliness of epidural pain relief.

  5. Luton and Dunstable Hospital NHS Foundation Trust

    Incorporate full clinical assessment requirements into the revised VBAC form for women undergoing induction after previous caesarean section.

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

  1. Luton and Dunstable Hospital NHS Foundation Trust

    Existing policies, guidelines, specialist counselling and individualised care plans are considered sufficient to support maternal Caesarean-choice requests while maintaining safety.

    Existing 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 respect mothers' requests for Caesarean Section delivery

Wider context from the report

“During the course of the Inquiry into the death of Baby Albie I heard that throughout labour his mother had asked for, and indeed, "begged" for a Caesarean Section delivery and her wish was not granted. She expressed concern that the delivery was following the same pattern as an earlier pregnancy and it had resulted in a delivery by emergency C Section. It was apparent that if baby Albie had been delivered when mother requested a C section he would have survived. My concern is that mothers requesting delivery by Caesarean Section are not having their wishes respected and this is putting babies' lives at risk. ”

Is this part of a recurring concern?

Yes — Unreliable mode-of-delivery decision-making.

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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 decision-making around non-elective caesarean sections to ensure appropriate classifications.

Verbatim wording from the response

“The following learning points were made as part of the Serious Incident Investigation and we confirm that all actions relating to these have been completed and implemented. We have attached the Action Plan for your consideration.”

Source location

2017-0015-Response-by-Luton-and-Dunstable-University-Hospital
Page 2 · response
Published 19 February 2017

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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 arising from the serious incident investigation.

Verbatim wording from the response

“Firstly, we would wish to offer our sincere condolences to Albie’s parents for the loss of their son and apologise for any experience that they felt was not as expected at the Luton and Dunstable University Hospital NHS Trust Maternity unit. We have reviewed the care as part of our investigations and the learning arising out of our investigations has been shared. Luton and Dunstable Hospital NHS Foundation Trust is committed to providing the highest quality care for all mothers and babies.”

Source location

2017-0015-Response-by-Luton-and-Dunstable-University-Hospital
Page 1 · response
Published 19 February 2017

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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

Ensure staff consider alternative delivery techniques earlier when managing an impacted fetal head.

Verbatim wording from the response

“The following learning points were made as part of the Serious Incident Investigation and we confirm that all actions relating to these have been completed and implemented. We have attached the Action Plan for your consideration.”

Source location

2017-0015-Response-by-Luton-and-Dunstable-University-Hospital
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

Consider how to improve the timeliness of epidural pain relief.

Verbatim wording from the response

“The following learning points were made as part of the Serious Incident Investigation and we confirm that all actions relating to these have been completed and implemented. We have attached the Action Plan for your consideration.”

Source location

2017-0015-Response-by-Luton-and-Dunstable-University-Hospital
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

Incorporate full clinical assessment requirements into the revised VBAC form for women undergoing induction after previous caesarean section.

Verbatim wording from the response

“The following learning points were made as part of the Serious Incident Investigation and we confirm that all actions relating to these have been completed and implemented. We have attached the Action Plan for your consideration.”

Source location

2017-0015-Response-by-Luton-and-Dunstable-University-Hospital
Page 2 · response
Published 19 February 2017

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 policies, guidelines, specialist counselling and individualised care plans are considered sufficient to support maternal Caesarean-choice requests while maintaining safety.

Verbatim wording from the response

“Unfortunately as not all of the respective clinicians directly involved in the delivery of care were called to attend the hearing and as live evidence on the discussion held with the respective disciplines of staff involved were not heard, we are confident the information contained in this response will reassure HM Senior Coroner respectfully that the Luton & Dunstable University Hospital NHS Trust does have policies and processes in place for mother’s requesting caesarean sections and our staff are skilled to understand and empower women of their right to choose for themselves whilst ensuring that the safety of mothers and infants remains paramount.”

Source location

2017-0015-Response-by-Luton-and-Dunstable-University-Hospital
Page 1 · 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