PFD report

Antonio Jerome Allen · Prevention of Future Deaths report

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Issued 31 Jul 2014•Manchester South

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
3

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. Unavailability of midwives for timely attendance at planned home births
    Part of recurring concern: Unreliable safety arrangements for midwifery-led home birth care
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

    Provide women with two telephone numbers for planned home-birth support.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2014.
  2. Action

    Reconnect the faulty dedicated telephone line.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2014.
  3. Action

    Establish a standard operating procedure for checking essential telephone lines function at the start of each shift.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2014.

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 midwives for timely attendance at planned home births

Wider context from the report

“It had been arranged that this was to be a home birth and the midwives based at Lostock Medical Centre were aware of this. His expected date of delivery was the 15th June but in fact he was born on the 17th June. The mother and grandmother of Antonio tried on four separate occasions to call out a midwife to attend the birth but in fact the delivery had to be carried out by the grandmother and a neighbour. Two midwives eventually arrived, checked the baby and said all was well although he was a bit ‘puffy’ because it was a ‘quick birth’. IF A HOME BIRTH IS BOOKED AND EXPECTED OR INDEED OVERDUE, IT SHOULD NOT BE THE CASE THAT THE MIDWIVES ARE NOT CONTACTABLE, NOR THAT THEY ARRIVE AFTER THE BIRTH HAS OCCURRED. ”

Is this part of a recurring concern?

Yes — Unreliable safety arrangements for midwifery-led home birth care.

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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 women with two telephone numbers for planned home-birth support.

Verbatim wording from the response

“On being informed by Midwife ████████ of the unanswered phone calls the administrator notified switchboard of the fault on the line and immediate action was taken to reconnect the telephone line. To ensure that this never happens again women are now given two telephone numbers to call in case one line is busy or faulty. A standard operating procedure in place to check that the essential telephone lines are fully functioning.”

Source location

2014-0351-Response-by-Central-Manchester-University-Hospitals-NHS
Page 2 · response
Published 31 July 2014

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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

Reconnect the faulty dedicated telephone line.

Verbatim wording from the response

“On being informed by Midwife ████████ of the unanswered phone calls the administrator notified switchboard of the fault on the line and immediate action was taken to reconnect the telephone line. To ensure that this never happens again women are now given two telephone numbers to call in case one line is busy or faulty. A standard operating procedure in place to check that the essential telephone lines are fully functioning.”

Source location

2014-0351-Response-by-Central-Manchester-University-Hospitals-NHS
Page 2 · response
Published 31 July 2014

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

Establish a standard operating procedure for checking essential telephone lines function at the start of each shift.

Verbatim wording from the response

“Following her return to the hospital Midwife ████████ alerted the radio telephone administration staff of the difficulties experienced by the family. On investigation it was identified that there had been a known fault on the telephone line earlier in the day but this had been resolved by the engineers. There is a process in place to ensure that the essential telephone lines are checked at the beginning of each shift; it was apparent that the administrator did not follow the process for checking the phone line at commencement of their shift so was unaware that the fault had reoccurred.”

Source location

2014-0351-Response-by-Central-Manchester-University-Hospitals-NHS
Page 2 · response
Published 31 July 2014

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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