PFD report

Malyun Habib KARAMA · Prevention of Future Deaths report

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Issued 21 Aug 2020•Inner North 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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

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 raised2

  1. Lack of national-level learning about the increased risk of uterine rupture in multigravida mothers
  2. Unavailability of a computer in the delivery suite for contemporaneous observation recording
    Part of recurring concern: Unreliable access to equipment for contemporaneous clinical-observation recording
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.3

  1. Action

    Share learning about the increased rupture risk for multiparous women with the national maternity risk and governance managers’ email forum.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2020.
  2. Action

    Review Labour Ward workstations on wheels to confirm computer availability in every labour room and identify required actions.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2020.
  3. Action

    Instruct staff to keep workstation-on-wheels carts in delivery rooms and report equipment problems through coordination, IT and incident-reporting channels.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2020.

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

  1. Position

    The Labour Ward had an appropriate number of workstations; the issue was staff removing workstation carts from labour rooms.

    Stated by Royal Free London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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-level learning about the increased risk of uterine rupture in multigravida mothers

Wider context from the report

“However, the Royal Free has not yet taken any steps to ensure that there is learning at a national level of the increased risk of rupture in a multi gravida mother. The more widely known increased risk is simply of vaginal birth after caesarean. ”

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

Unavailability of a computer in the delivery suite for contemporaneous observation recording

Wider context from the report

“Also, one of the midwives looking after Malyun Karama explained that there was no computer in the delivery suite and so she could not record her observations contemporaneously or without leaving the room. This is sub optimal. ”

Is this part of a recurring concern?

Yes — Unreliable access to equipment for contemporaneous clinical-observation recording.

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

Share learning about the increased rupture risk for multiparous women with the national maternity risk and governance managers’ email forum.

Verbatim wording from the response

“• Learning in relation to the increased risk of rupture in relation to multigravida women to be shared with the national maternity risk/governance managers email distribution forum. This was completed on 2 October 2020 and the email that was distributed has been embedded into the attached action plan.”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 2 · response
Published 26 October 2020

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 Labour Ward workstations on wheels to confirm computer availability in every labour room and identify required actions.

Verbatim wording from the response

“The Action required is for a review to take place of the workstations on wheels (WOW) on the Labour Ward to ensure that all Labour rooms possess a computer for staff use.”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 2 · response
Published 26 October 2020

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

Instruct staff to keep workstation-on-wheels carts in delivery rooms and report equipment problems through coordination, IT and incident-reporting channels.

Verbatim wording from the response

“This review was completed on 2 September 2020 and it identified that there were the appropriate number of workstation on wheels for the Labour rooms. However it was identified that staff were removing the Wow carts from the Labour rooms. This gave rise to recommendations being sent out via email on 2 September 2020 that:”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 2 · response
Published 26 October 2020

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 Labour Ward had an appropriate number of workstations; the issue was staff removing workstation carts from labour rooms.

Verbatim wording from the response

“Review completed – The review identified that there were the appropriate number of workstation on wheels for the Labour rooms – however it was identified that staff were removing the WOW carts from the Labour rooms.”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 6 · response
Published 26 October 2020

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.7

  1. 1

    Share incident learning with the NHS England and NHS Improvement London Maternity Clinical Network project manager.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2020.
  2. 2

    Present the case at the NCL Local Maternity System Quality and Safety Meeting.

    Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
  3. 3

    Conduct spot checks of compliance with the revised misoprostol regimen during a defined monitoring period.

    Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
  4. 4

    Develop an e-learning package reflecting the revised Bereavement/Pregnancy Loss guideline for midwifery and obstetric staff.

    Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2020.
  5. 5

    Send staff a memo explaining the additional amendments to the Bereavement/Pregnancy Loss guideline.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2020.
  6. 6

    Update and disseminate the Bereavement/Pregnancy Loss guideline with revised misoprostol regimens, parity-specific dosing, obstetric review requirements and termination-of-pregnancy guidance.

    Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2020.
  7. 7

    Deliver junior doctor teaching on the revised Bereavement/Pregnancy Loss guidance.

    Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.

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 incident learning with the NHS England and NHS Improvement London Maternity Clinical Network project manager.

Verbatim wording from the response

“• Learning from the incident to be shared with the Project Manager for the Maternity Clinical Network – NHS England and NHS Improvement – London Region. This was completed on 2 October 2020 and the email that was distributed has been embedded into the attached action plan.”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 2 · response
Published 26 October 2020

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

Present the case at the NCL Local Maternity System Quality and Safety Meeting.

Verbatim wording from the response

“• For the case to be presented at the NCL (North Central London) Local Maternity System Quality and Safety Meeting. This is set to take place on 6 November 2020.”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 2 · response
Published 26 October 2020

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 spot checks of compliance with the revised misoprostol regimen during a defined monitoring period.

Verbatim wording from the response

“c. Spot check of compliance with the new regimen for Misoprostol to be undertaken by the Bereavement midwives for a three-month period to ensure this practice is embedded. This will be performed over two months due to the small numbers of cases.”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 5 · response
Published 26 October 2020

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

Develop an e-learning package reflecting the revised Bereavement/Pregnancy Loss guideline for midwifery and obstetric staff.

Verbatim wording from the response

“E-learning package – Deadline for completion of action 5 October 2020.”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 4 · response
Published 26 October 2020

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 staff a memo explaining the additional amendments to the Bereavement/Pregnancy Loss guideline.

Verbatim wording from the response

“b. A memo to be sent to staff of the changes to the Bereavement/Pregnancy Loss guideline.”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 5 · response
Published 26 October 2020

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 and disseminate the Bereavement/Pregnancy Loss guideline with revised misoprostol regimens, parity-specific dosing, obstetric review requirements and termination-of-pregnancy guidance.

Verbatim wording from the response

“1. | ‘I heard evidence of changes in systems at the Royal Free Hospital following the events of 20 February 2020, including changing the misoprostol dose protocol and making a medical review mandatory before each administration to a multi gravida mother. However, the Royal Free has not yet taken any steps to ensure that there is learning at a national level of the increased risk of rupture in a multi gravida mother. The more widely known increased risk is simply of vaginal birth after caesarean. | a. The Bereavement/Pregnancy Loss guideline updated to include the following and disseminated via the Trust intranet: - The regimen for Misoprostol to be in line with national guidance - Clear guidance on the dosage for women receiving misoprostol for induction of an intrauterine death depending on their parity.”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 4 · response
Published 26 October 2020

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

Deliver junior doctor teaching on the revised Bereavement/Pregnancy Loss guidance.

Verbatim wording from the response

“Junior doctor teaching – Deadline for completion of action 30 October 2020. | Revised Bereavement/Pregnancy Loss guideline – April version”

Source location

2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 4 · response
Published 26 October 2020

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