PFD report

Willow Davies · Prevention of Future Deaths report

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Issued 21 Apr 2015•Bedfordshire and Luton

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised3

  1. Failure to provide further support to midwives without experience in newborn resuscitation
    Part of recurring concern: Inadequate competence assurance and supervision for inexperienced midwivesPart of recurring concern: Inadequate competence in neonatal resuscitation
  2. Failure of the Supervisors of Midwives system to support pregnant women and midwives
    Part of recurring concern: Failure to provide adequate supervision of care staff
  3. Failure to take individual midwife experience into account when allocating women on shifts
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.4

  1. Action

    Risk-assess case complexity at handover and throughout each shift, allocate women according to staff experience and competence, and record four-hourly reviews.

    Stated by Bedford HospitalStated completedThe respondent said that this action was complete when they made their response on 21 April 2015.
  2. Action

    Provide new starter midwives with a structured orientation period, nominated preceptor and managerial and supervisory support tailored to learning needs.

    Stated by Bedford HospitalStated completedThe respondent said that this action was complete when they made their response on 21 April 2015.
  3. Action

    Provide pregnant women with information on accessing Supervisors of Midwives and maintain round-the-clock, year-round supervisory availability for women and staff.

    Stated by Bedford HospitalStated completedThe respondent said that this action was complete when they made their response on 21 April 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    The allocation of the newly qualified midwife to the low-risk case was considered appropriate at the time and after review.

    Stated by Bedford HospitalDisputes 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

Failure to provide further support to midwives without experience in newborn resuscitation

Wider context from the report

“1. That a newly qualified Midwife was allocated to deliver a baby when, during the course of her training and her practice since qualifying, she had never assisted with the resuscitation of a new born baby. The Midwife had no further support. ”

Is this part of a recurring concern?

Yes — Inadequate competence assurance and supervision for inexperienced midwives; Inadequate competence in neonatal resuscitation.

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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 of the Supervisors of Midwives system to support pregnant women and midwives

Wider context from the report

“3. That system of ‘Supervisors of Midwives’, as it operates at Bedford Hospital, is in urgent need of review to ensure that it is working to support pregnant women and midwives in the Trust. ”

Is this part of a recurring concern?

Yes — Failure to provide adequate supervision of care staff.

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 take individual midwife experience into account when allocating women on shifts

Wider context from the report

“2. That the allocation of women to midwives on a shift by shift basis did not, and does not, take into account the experience of the individual midwife ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Risk-assess case complexity at handover and throughout each shift, allocate women according to staff experience and competence, and record four-hourly reviews.

Verbatim wording from the response

“There is a senior midwife in charge of each shift in Delivery Suite, often without a case load of their own. He/she risk assesses the complexity of the case mix of women/patients at every handover, using the SBAR (Situation, Background, Assessment, Recommendation) tool and allocates the care of women accordingly, taking into account staff experience, competencies and confidence. The position is continually assessed throughout the shift, taking into account such factors as admissions to the Delivery Suite, clinical complications developing during delivery, the increasing complexity of workload and the available capacity within the unit.”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 2 · response
Published 21 April 2015

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

Provide new starter midwives with a structured orientation period, nominated preceptor and managerial and supervisory support tailored to learning needs.

Verbatim wording from the response

“The Trust recognises that all new members of staff, whatever their experience, need a period of time to become familiar with local procedures and practices. Within the Maternity Unit at Bedford Hospital, an orientation period is allocated. ‘New starters’ unfamiliar with the Trust (including a newly qualified midwife) would undertake this programme for up to a month. Within this period, the new starter works with a nominated midwife for support and is expected to complete a bespoke orientation programme, developed following discussion”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 1 · response
Published 21 April 2015

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

Provide pregnant women with information on accessing Supervisors of Midwives and maintain round-the-clock, year-round supervisory availability for women and staff.

Verbatim wording from the response

“A SoM Information Leaflet, based on the NMC leaflet “Support for Parents - How supervision and supervisors of midwives can help you “ (2009) is given to every pregnant woman when she registers her pregnancy through a process called ‘booking’. This leaflet sign-posts the family on how to access a Supervisor of Midwives and outlines the functions of statutory supervision. Bedford Hospital SoMs have an ‘on call’ rota, covering 24 hours availability, 365 days a year, and may be contacted by both users of the service and staff working both locally and regionally, for advice and support. The family in this tragic case had the involvement of a SoM during and after the completion of the investigation and prior to, during and since the Coroner’s Inquest Hearing.”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 3 · response
Published 21 April 2015

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

Require all employed midwives to complete annual neonatal resuscitation theory and simulation training under accredited trainers.

Verbatim wording from the response

“Neonatal resuscitation through assimilation assessment forms one part of the interview and selection process for recruiting all midwives to the maternity unit at Bedford Hospital.”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 1 · response
Published 21 April 2015

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 allocation of the newly qualified midwife to the low-risk case was considered appropriate at the time and after review.

Verbatim wording from the response

“Baby Willow’s mother was classified as a ‘low risk’ case throughout her pregnancy and this classification was not changed on her admission to the Delivery Suite or throughout labour. The hospital Clinical Guideline for ‘Care of women in labour in all care settings’ (copy attached) fully describes the Care of Healthy Women and Babies in Normal Labour (Section 2).”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 3 · response
Published 21 April 2015

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

A second person is not required at birth; midwives must request support when clinically necessary, with assistance available through existing arrangements.

Verbatim wording from the response

“The Nursing and Midwifery Council does not stipulate that a midwife must have a second person in attendance at the time of the birth. When the Trust’s Head of Midwifery raised this issue at a meeting of the Contact Supervisor of Midwives’ meeting in April 2015, it was confirmed that this approach is replicated in maternity units across the East Midlands and East of England region. In line with the Code of Conduct and local Trust policy, it is the responsibility of the midwife to request support if he/she requires it.”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 3 · response
Published 21 April 2015

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 statutory Supervision of Midwives system complies with applicable standards and is considered effective in supporting mothers and midwives.

Verbatim wording from the response

“The statutory Supervision of Midwifery system in the Trust is modelled on the recommendations in the Local Supervising Authority Standards for Supervision (2009). An annual Supervision of Midwifery (SoM) Report is received by the Trust Board and Local Supervising Authority for Midwifery and this demonstrates full compliance.”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 3 · response
Published 21 April 2015

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 shift allocation procedures assess case complexity, staff experience and competence, sufficiently reducing the risk of inappropriate staff allocation.

Verbatim wording from the response

“There is a senior midwife in charge of each shift in Delivery Suite, often without a case load of their own. He/she risk assesses the complexity of the case mix of women/patients at every handover, using the SBAR (Situation, Background, Assessment, Recommendation) tool and allocates the care of women accordingly, taking into account staff experience, competencies and confidence. The position is continually assessed throughout the shift, taking into account such factors as admissions to the Delivery Suite, clinical complications developing during delivery, the increasing complexity of workload and the available capacity within the unit.”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 2 · response
Published 21 April 2015

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 training, orientation, supervision and emergency support systems sufficiently address risks from limited hands-on neonatal resuscitation experience.

Verbatim wording from the response

“The Trust considers therefore that the systems and processes that it had and still does have in place in relation to this concern meet national requirements. Practices are in line with practices in other maternity units. This minimises the risk from lack of ‘hands on’ practical experience and ensures that staff have the required skills and support when needed.”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 2 · response
Published 21 April 2015

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.2

  1. 1

    Submit an annual Supervision of Midwifery report to the Trust Board and Local Supervising Authority to demonstrate compliance.

    Stated by Bedford HospitalStated completedThe respondent said that this action was complete when they made their response on 21 April 2015.
  2. 2

    Assess neonatal resuscitation competence during recruitment of midwives to the maternity unit.

    Stated by Bedford HospitalStated completedThe respondent said that this action was complete when they made their response on 21 April 2015.

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

Submit an annual Supervision of Midwifery report to the Trust Board and Local Supervising Authority to demonstrate compliance.

Verbatim wording from the response

“The statutory Supervision of Midwifery system in the Trust is modelled on the recommendations in the Local Supervising Authority Standards for Supervision (2009). An annual Supervision of Midwifery (SoM) Report is received by the Trust Board and Local Supervising Authority for Midwifery and this demonstrates full compliance.”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 3 · response
Published 21 April 2015

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

Assess neonatal resuscitation competence during recruitment of midwives to the maternity unit.

Verbatim wording from the response

“Neonatal resuscitation through assimilation assessment forms one part of the interview and selection process for recruiting all midwives to the maternity unit at Bedford Hospital.”

Source location

2015-0157-Response-by-Bedford-Hospital-NHS-Trust
Page 1 · response
Published 21 April 2015

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