PFD report

Leo Deady · Prevention of Future Deaths report

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Issued 14 Oct 2013•Inner South 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.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
0

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 detect breech presentation before delivery
    Part of recurring concern: Failure to provide individualised pregnancy and birth risk assessment and planning
  2. Lack of national consideration of the risks and benefits of routine late-pregnancy scanning
  3. Lack of national guidelines on routine late-pregnancy scanning for breech presentation
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

    Routine national late-pregnancy scanning is not considered beneficial based on existing evidence, so developing a national system is unnecessary.

    Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that 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

Failure to detect breech presentation before delivery

Wider context from the report

“(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed. The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high. Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed. The only certain way of detecting breech presentation is by scan. The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech. The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy. There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues. ”

Is this part of a recurring concern?

Yes — Failure to provide individualised pregnancy and birth risk assessment and planning.

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

Lack of national consideration of the risks and benefits of routine late-pregnancy scanning

Wider context from the report

“(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed. The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high. Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed. The only certain way of detecting breech presentation is by scan. The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech. The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy. There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues. ”

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

Lack of national guidelines on routine late-pregnancy scanning for breech presentation

Wider context from the report

“(1) The evidence given at the inquest was that there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed. The percentage of undiagnosed breech presentations may be as high as 25%. The risks of vaginal breech delivery are very high. Although midwives (especially experienced midwives as in this case) pick up most cases of breech presentation, it is clear that a small but significant number are missed. The only certain way of detecting breech presentation is by scan. The evidence in this case was that there are no national guidelines as to whether hospitals should routinely scan at a late stage of pregnancy to exclude breech. The evidence at this inquest was that some London hospitals do carry out routine scanning in late pregnancy. There was no evidence available at the inquest to say whether the risks and benefits of routine scanning in late pregnancy has been considered nationally in the light of potential funding issues. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Routine national late-pregnancy scanning is not considered beneficial based on existing evidence, so developing a national system is unnecessary.

Verbatim wording from the response

“In October 2008, the Cochrane Review into The Routine ultrasound in late pregnancy (after 24 weeks’ gestation) concluded that, based on existing evidence, routine late pregnancy ultrasound in low-risk or unselected populations does not confer benefit on mother or baby.”

Source location

2013-0369-Response-by-Department-of-Health
Page 2 · response
Published 19 December 2013

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