PFD report

Vinnie William Ord Dodds · Prevention of Future Deaths report

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Issued 20 Jul 2021•Sunderland

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.

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Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

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 standardised counselling about fatal risks associated with shoulder dystocia
    Part of recurring concern: Unreliable mode-of-delivery decision-making
  2. Lack of clear guidance on the optimal timing of glucose tolerance testing
  3. Failure to include the risk of death from shoulder dystocia in patient information
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Available evidence is insufficient to recommend induction over expectant management for suspected fetal macrosomia without diabetes.

    Stated by Department of Health and Social CareUnable 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

Lack of standardised counselling about fatal risks associated with shoulder dystocia

Wider context from the report

“Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic. The Trust carried out and acted on a full review. However, there are concerns of wider significance: - 1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present, so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby. a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks? b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)? c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise. 2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks? 3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013). ”

Is this part of a recurring concern?

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

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 the optimal timing of glucose tolerance testing

Wider context from the report

“Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic. The Trust carried out and acted on a full review. However, there are concerns of wider significance: - 1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present, so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby. a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks? b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)? c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise. 2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks? 3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013). ”

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

Failure to include the risk of death from shoulder dystocia in patient information

Wider context from the report

“Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic. The Trust carried out and acted on a full review. However, there are concerns of wider significance: - 1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present, so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby. a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks? b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)? c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise. 2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks? 3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013). ”

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 national guidance on management and counselling thresholds for large babies in pregnancy

Wider context from the report

“Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic. The Trust carried out and acted on a full review. However, there are concerns of wider significance: - 1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present, so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby. a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks? b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)? c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise. 2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks? 3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013). ”

Is this part of a recurring concern?

Yes — Inadequate guidance for managing large babies in pregnancy and birth.

Open source report

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

Available evidence is insufficient to recommend induction over expectant management for suspected fetal macrosomia without diabetes.

Verbatim wording from the response

“The aim of the evidence review was to determine if Induction of Labour for suspected fetal macrosomia at, or after, 35 weeks gestation, has benefits and reduces the risk of adverse outcomes for the mother and the baby, compared to expectant management. The review looked at all women apart from those with treated diabetes (pre-existing or gestational). The review looked at the following outcomes; third/fourth degree tears; shoulder dystocia; perinatal death; hypoxic ischaemic encephalopathy; maternal satisfaction; brachial plexus injury; and, caesarean birth.”

Source location

2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
Page 4 · response
Published 22 July 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

There is insufficient evidence to recommend glucose tolerance testing specifically at 26 weeks.

Verbatim wording from the response

“Healthcare professionals should offer women with any of the other risk factors for gestational diabetes (outlined in recommendation 1.2.2) a 75-g 2-hour OGTT at 24 to 28 weeks (recommendation 1.2.7). NICE advises that it does not consider that there is sufficient evidence to make a recommendation for OGTT at 26 weeks.”

Source location

2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
Page 5 · response
Published 22 July 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 existing 24-to-28-week testing window provides flexibility for arranging glucose tolerance tests around 26 weeks.

Verbatim wording from the response

“I am further advised by NHSEI that in clinical practice, glucose tolerance tests are routinely arranged to be performed at around 26 weeks gestation and that the 24-28 week recommendation allows some flexibility should there be a problem with the woman attending at exactly 26 weeks.”

Source location

2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
Page 5 · response
Published 22 July 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 NICE guidance adequately covers counselling and birth options for women with suspected large babies.

Verbatim wording from the response

“1.17.3 Offer women in labour whose babies are suspected to be large for gestational age a choice between continuing labour, including augmented labour, and caesarean section.”

Source location

2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
Page 3 · response
Published 22 July 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