Jannat ABBKER · Prevention of Future Deaths report

On 23 August 2024, one of my assistant coroners, Edwin Buckett, commenced an investigation into the death of Jannat Abbker, a baby who died shortly after birth. The investigation concluded at the end of the inquest yesterday. I made a determination at inquest that Jannat died as a consequence of trauma suffered during birth as a result of shoulder dystocia.

Jannat was a big baby and her mother had a history of shoulder dystocia with two out of her three previous pregnancies. Her mum received midwifery and obstetric care for the two pregnancies at University College London Hospital (UCLH), and Jannat was delivered there.

Unfortunately, the fact of the shoulder dystocia was not communicated to Jannat’s parents after the earlier births, and was not recognised by the staff at UCLH during this pregnancy. If it had been, Jannat’s mother would have been offered a Caesarean section for Jannat’s delivery. A Caesarean section would have avoided the shoulder dystocia that caused Jannat’s death.

With the benefit of a maternity and newborn safety investigation (MNSI), UCLH is undertaking a significant piece of work to improve its systems.

However, there remains one outstanding point. When all else had failed, Jannat was finally delivered by use of a manoeuvre called a shoulder shrug. I heard at inquest that this is not a manoeuvre included within the NICE (National Institute for Health and Care Excellence) guidelines, but it is used abroad. One of the obstetric registrars looking after Jannat’s mother had seen it in a training video.

I wonder if there is merit in considering this for inclusion in the next set of relevant NICE guidelines, whenever these are updated?