PFD report

Evelyn Grace March · Prevention of Future Deaths report

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Issued 19 Sep 2024•West Yorkshire Eastern

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised1

  1. Premature discharge after prolonged labour and induced delivery
    Part of recurring concern: Unreliable hospital discharge processes
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.1

  1. Position

    Immediate postnatal care and discharge were considered compliant with national guidance, so earlier discharge arrangements were not changed.

    Stated by Leeds Teaching Hospitals NHS TrustExisting 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

Premature discharge after prolonged labour and induced delivery

Wider context from the report

“4. Consideration should be given to the wisdom of discharging a mother so soon after a prolonged labour and induced delivery. Had she been permitted to sleep in hospital for a few hours knowing that her baby was being monitored, the tragedy may have been avoided. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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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

Immediate postnatal care and discharge were considered compliant with national guidance, so earlier discharge arrangements were not changed.

Verbatim wording from the response

“I respectfully note that you state that consideration should be given to the wisdom of discharging a mother so soon after a prolonged labour and delivery.”

Source location

Response from Leeds Teaching Hospitals
Page 2 · response
Published 19 September 2024

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.1

  1. 1

    Update the induction-of-labour leaflet with advice on ward supplies, comfort items and the possibility that induction may take several days.

    Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Independent reviews found no care issues that impacted the death and identified no safety recommendations.

    Stated by Leeds Teaching Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 induction-of-labour leaflet with advice on ward supplies, comfort items and the possibility that induction may take several days.

Verbatim wording from the response

“Evelyn’s mother ████████ and father ████████ both reported concerns to the Trust as part of the mortality review process and the SUDIC process that ████████ felt exhausted and that the delay in the induction of labour contributed to this. The Trust has subsequently updated the leaflet it provides to mothers about the induction of labour. This now includes information around bringing isotonic drinks and snacks to the ward, along with other items which may support them, such as eye masks, ear plugs and their own pillows. The leaflet also reiterates that the process of induction can take several days.”

Source location

Response from Leeds Teaching Hospitals
Page 2 · response
Published 19 September 2024

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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

Independent reviews found no care issues that impacted the death and identified no safety recommendations.

Verbatim wording from the response

“Evelyn’s death was reviewed using the National Perinatal Mortality Review Tool (PMRT), was subject to scrutiny under the Sudden Unexplained Death in Childhood (SUDIC) process and was investigated independently by MNSI.”

Source location

Response from Leeds Teaching Hospitals
Page 2 · response
Published 19 September 2024

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