Eddie Coffey

From Nadine Dorries MP 
Minister of State for Patient Safety, 
Suicide Prevention and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

Our Ref: 

Mr Jonathan Stevens 
HM Assistant Coroner, Hertfordshire 
HM Coroner's Office 
The Old Court House 
St Albans Road East 
Hatfield AL10 0ES 

9 February 2021 

Dear Mr Stevens  

Thank you for your letter of 15 December 2020 to Matt Hancock about the death of Eddie 
John Coffey.  I am responding as Minister with responsibility for maternity care.   

Firstly, I would like to say how deeply sorry I was to read of the circumstances of baby 
Eddie’s death and I offer my most sincere condolences to Eddie’s parents and family.  I 
appreciate how devastating it must be to lose a child and that the pain must be particularly 
hard to bear when there are concerns about the care provided.  

It is essential that the East and North Hertfordshire NHS Trust (the Trust) takes all the 
learnings from the circumstances of Eddie’s death and the findings of your investigation to 
prevent future tragedies.  

I am advised by the Care Quality Commission (CQC), the independent regulator for 
quality, that maternity services at the Trust were inspected in April 2018, resulting in an 
overall rating of Good and Requires Improvement for the safety of care.  The CQC has 
monitored the improvements made by the Trust that include a move to physiological CTG 
interpretation1 supported by one full day of CTG training.  The CQC was advised by the 
Trust that as at October 2020, 86 per cent of midwives and 73 per cent of medical staff 
had received additional training in fetal monitoring during labour.   

I am further advised that an inspection of the Trust in June 2019 rated overall leadership 
as Requires Improvement reflecting that at that time, the Trust was developing its patient 
safety culture and strengthening its governance processes around incident management 
to ensure learning. 

1 Physiological interpretation of cardiotocography. A technique used to monitor the fetal heart rate to assess 
fetal wellbeing.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I welcome the action that has been taken so far and I encourage the Trust to continue to 
look carefully at what more can be done to improve this important area of patient safety.  
In line with regulatory processes, I am assured that the CQC will continue to monitor 
improvements at the Trust and my officials have brought your report to the attention of 
health system leaders, NHS England and NHS Improvement (NHSEI).  

To ensure patient safety, it is vitally important that NHS Trusts encourage a culture of 
openness and continuous learning.  That is why, in 2017, the National Quality Board 
published national guidance on Learning from Deaths2, to introduce a more standardised 
approach to the way NHS trusts review, investigate and learn from deaths thought to be 
due to problems in care.    

From 2017-18, we have required NHS trusts to publish locally the numbers of deaths 
thought to be due to problems in care on a quarterly basis, and to evidence what they 
have learned and the actions taken to prevent such deaths on an annual basis in their 
Quality Accounts.  This new level of transparency is fundamental to a culture of learning 
and ensuring the safety of NHS services.  This policy is supported by strengthened 
inspection assessment of NHS trusts’ learning from deaths by the independent regulator 
for quality, the CQC.  

In relation to your findings about the quality of the Trust’s investigation of the care and 
treatment provided to Eddie Coffey and his mother during labour, you may wish to note 
that a new Patient Safety Incident Response Framework3, to replace the Serious Incident 
Framework, is being developed to facilitate examination of a wider range of patient safety 
incidents in the NHS and to improve the quality of patient safety incident investigation and 
how organisations can learn and change as a result.   

The Framework outlines how NHS organisations should respond to patient safety 
incidents, including how and when an investigation should be conducted.  The Framework 
supports a systematic, compassionate and proficient response; anchored in the principles 
of openness, fair accountability, learning and continuous improvement.   

NHSEI is currently working with early adopters to pilot the new Framework.  The learning 
from this pilot will be used to inform the final version of the Framework.  Until this is 
finalized, NHS providers and their local health partners should review the introductory 
framework and Patient Safety Incident Investigation standards4 and begin to consider what 
they will need to do to support their implementation.  

Turning to your wider concerns about maternity safety, I wish to assure you that there is 
much being done nationally to improve the quality and safety of maternity services.   

2 https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf 

3 https://www.england.nhs.uk/patient-safety/incident-response-framework/ 

4 https://www.england.nhs.uk/patient-safety/patient-safety-investigation/ 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
  first report, Emerging Findings and 

Following the publication of 
Recommendations from the Independent Review of Maternity Services at the Shrewsbury 
and Telford Hospitals NHS Trust, on 10 December 2020, NHSEI wrote to NHS Trust and 
Foundation Trust Chief Executives and Chairs5, setting out the immediate response 
required of all NHS Trusts providing maternity services and next steps to be taken 
nationally.  Despite considerable progress having been made in improving maternity 
safety, there continues to be too much variation in experience and outcomes for women 
and their families.  

This letter identifies seven priorities and has asked NHS Trusts for immediate actions to 
implement these, including: enhanced safety; listening to women and their families; staff 
training and working together; managing complex pregnancy; risk assessment throughout 
pregnancy; monitoring fetal wellbeing; and informed consent. 

In relation to monitoring fetal wellbeing, NHS Trusts are being asked to implement the 
saving babies lives bundle.  Element 4 of the Saving Babies Lives Care Bundle Version 2 
(SBLCBv26) already states there needs to be one lead with the responsibility of improving 
the standard of fetal monitoring.  NHS Trusts are now being asked to ensure that a second 
lead is identified so that every unit has a lead midwife and a lead obstetrician in place to 
lead best practice, learning and support. This will include regular training sessions, review 
of cases and ensuring compliance with the SBLCBv2 and national guidelines. 

 report also identified that safe delivery of maternity services is 

dependent on a multidisciplinary team approach.  The Maternity Transformation 
Programme7, led by NHSEI, has implemented a range of interventions to increase 
numbers of healthcare professionals and support workers including the development of the 
maternity support worker role; the expansion of midwifery undergraduate numbers; 
additional maternity placements; and active recruitment. 

In addition, £9.4million was awarded in the 2020 Spending Review to support maternity 
safety pilots that will include fresh learning from recent investigations and academic 
research to be used to improve clinical practice during childbirth, and cutting-edge training 
and expert guidance to improve practice and avoid harm to babies. 

In relation to guidelines on monitoring fetal heart rate, there are different guidelines for 
fetal heart rate monitoring that NHS Trusts in England may refer to in developing their local 
guidelines.  This includes: 

•  NICE (National Institute for Health and Care Excellence) ‘Intrapartum care for 

healthy women and babies’ Clinical guideline [CG1908] which includes guidelines 
on fetal monitoring in labour; and,  

5 https://www.england.nhs.uk/wp-content/uploads/2021/01/Ockenden-Letter-CEO-Chairs-final-14.12.20-1.pdf 

6 https://www.england.nhs.uk/wp-content/uploads/2019/07/saving-babies-lives-care-bundle-version-two-
v5.pdf 

7 https://www.england.nhs.uk/mat-transformation/ 

8 https://www.nice.org.uk/guidance/CG190 

 
 
 
 
 
 
 
 
 
 
 
 
 
 •  FIGO (International Federation of Gynaecology and Obstetrics) ‘Consensus 

guidelines on intrapartum fetal monitoring: Cardiotocography9’. 

In addition, there is a third approach called ‘Physiological CTG Interpretation’ developed 
by clinicians from St George’s Hospital, Lewisham and Greenwich NHS Trust and 
Kingston Hospital, led by 
Part of the Spending Review 2020 investment of £9.4million is to pilot an approach to risk 
assessment and escalation of fetal deterioration, including fetal heart rate monitoring that 
can be standardised across all maternity providers in England. 

10. 

Finally, my officials have brought your report to the attention of the Healthcare Safety 
Investigation Branch (HSIB).  HSIB is a key part of our commitment to improve patient 
safety and the culture of learning in the NHS.  The HSIB conduct independent maternity 
investigations that meet the Each Baby Counts criteria and a defined criteria for maternal 
deaths so that the NHS learns quickly from what went wrong and uses this to prevent 
future tragedies.  Where HSIB identifies systemic risks, it can consider making national 
recommendations for system change.   

I hope this response is helpful.  Thank you for bringing these concerns to my attention.  

MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH 

NADINE DORRIES 

9 https://www.figo.org/news/available-view-figo-intrapartum-fetal-monitoring-guidelines 

10 https://www.icarectg.com/wp-content/uploads/2018/03/Intrapartum-Fetal-Monitoring-Guideline.pdf

Lister Hospital 
Coreys Mill Lane 
Stevenage 
Hertfordshire  
SG1 4AB 

Our Ref:  
Direct Line: 
Email: 

5 February 2021 

Mr Jonathan Stevens  
Assistant Coroner for Hertfordshire    
The Old Courthouse  
St Albans Road East 
Hatfield  
Hertfordshire 
AL10 0ES 

Dear Mr Stevens 

Eddie Coffey (Deceased) 

I am writing in response to your Regulation 28 report to Prevent Future Deaths, which was 
received 15 December 2020, regarding the above named.  I was saddened to learn of the sad 
circumstances of Eddie’s death on 14 January 2019.  I will answer each of your matters of 
concern in turn. 

In relation to the first matter of concern, we are acutely aware that the conclusion of the Serious 
Incident  (SI)  investigation  was  contradicted  by  the  evidence  heard  at  the  Inquest.    The  SI 
investigation report reflected the information provided by the relevant clinical staff and it was 
felt that it was a valid and accurate reflection on the care service delivery issues identified.  As 
you know, as part of the SI investigation the Trust requested an external independent opinion 
on the CTG trace from 
.  The scope of that opinion was limited to asking his 
opinion  on  what  the  CTG  trace  showed.    I  understand  that  as  part  of  your  Inquest  you 
subsequently obtained a formal report from him that went into more depth and in turn brought 
with it further criticisms.  When obtaining an independent third-party or independent clinical 
opinion in the future the trust will ensure this is done on a more formal basis with clear terms 
of reference.   

The Trust is fully committed to learning from all SI investigations and part of the report includes 
a list of ‘recommendations’ that the author compiles in response to any ‘care / service delivery 
problems’ that the investigation has identified.  It is the responsibility of the clinical team to 
prepare an action plan in response to those recommendations and to ensure learning from 
the incident. Action plans are developed by the multi-disciplinary clinical team and monitored 
through divisional governance meetings.  

In addition, the Maternity team undertake peer reviews, resulting in transparency and ongoing 
oversight  of  action  plans  and  learning  across  the  Local  Maternity  and  Neonatal  System 
(LMNS).  At  monthly  LMNS  safety  meetings  all  SI’s,  actions  and  Quality  Improvement  (QI) 
projects from them along with the progress of embedding the QI are discussed. Furthermore, 

Chief Executive:  

    Trust Chair:  

 
 
 
 
 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the Directors of Midwifery and the LMNS Programme Lead have agreed a standard operating 
procedure for LMNS oversight of SI investigations and action plans going forward.  

Taking your second and third points together, we have noted the evidence given at the Inquest 
by the Trust’s Consultant Obstetrician and the independent Consultant Obstetrician. However, 
as also was discussed at the Inquest and stated in the ‘Saving Babies Lives’ bundle 2 (NHS 
England,  March  2019),  ‘CTG  monitoring  is  a  well-established  method  of  confirming  fetal 
wellbeing and screening for fetal hypoxia…However, CTG interpretation is a high-level skill 
and is susceptible to variation in judgement between clinicians and by the same clinician over 
time. These variations can lead to inappropriate care planning and subsequently impact on 
perinatal outcomes’. Differing interpretations of CTG recordings is therefore a recognised risk. 
In  order  to  mitigate  against  this  risk,  the  Trust  is  committed  to  enhancing  our  already  well 
established Fetal Monitoring training, and in particular enhancing the training provided to staff 
with regards to the second stage of labour. The importance of this issue is highlighted in every 
Fetal Monitoring lecture as maternal pulse features and characteristics are included as well 
as  being  included  in  an element  of the  Human  Factors  training that  is given.  The  intended 
impact of this is to ignite professional curiosity and to encourage clinicians to actively seek out 
to exclude maternal pulse. Furthermore, since 20 January 2020 the trust has employed a full 
time  fetal  monitoring  specialist  midwife  for  12  months.  This  midwife  provides  specialist 
guidance, teaches staff about the physiological approach, works clinically on the unit reviewing 
CTG’s and leads on fetal monitoring education with the Consultant Obstetrician. As a result of 
the work described above, our internal fetal monitoring assessment which was introduced in 
2019 has maintained a pass rate of 98%. 

In response to your fourth point, actions have been developed to further strengthen the training 
in relation to second stage fetal monitoring interpretation. A second stage training update was 
delivered on 19 January 2021 which focussed on fetal monitoring and recognising the signs 
to differentiate between maternal pulse and fetal heart rate, highlighting learning from themes 
and incidents. Further sessions have been planned in this regard. An Intermittent Auscultation 
and  escalation  competency  package,  using  added  case  scenarios  including  small  group 
sessions  and  annual training,  is  being  rolled  out to  the  Midwifery-Led-Unit  (MLU) midwives 
supported by a plan to role this out to all midwives. This will include a competency - based 
assessment and a requirement to record pass rates for ongoing auditing and assurance.   

Notwithstanding the training that has been implemented already at the Trust, it is accepted 
that CTG technology is not straightforward. This has led to a review being undertaken of the 
CTG  machines  currently  in  use  within  the  Trust.    As  a  department,  Maternity  are  working 
towards  standardising  equipment  in  line  with  best  practice.    Review  of  the  CTG  machines 
currently in use has identified that 6 new machines are required which would then mean that 
all of the machines in use are the same and all would record maternal pulse on the CTG trace.  
Further work towards the procurement of these machines is ongoing and being reviewed by 
our  Capital  Equipment  Committee.    This  issue  will  be  added  to  the  risk  register  which  will 
ensure oversight and enable clear monitoring on a regular basis.     

Moreover, in terms of immediate practical steps taken, we are in the process of producing a 
visual sticker that will go at the front of a CTG machine after a woman is transferred from MLU 
to  CLU. This  sticker  will  include  a  box for  two  individuals  to check  and  sign that they  have 
independently palpated maternal pulse.  This process will be in place by the end of February 
2021. 

We have also reviewed the emerging findings and recommendations from the first Ockenden 
Report in their ongoing review of Maternity Services at Shrewsbury and Telford Hospital Trust 
published in December 2020. As you may already be aware, one action in this report relates 

Chief Executive:  

    Trust Chair:  

 
 
 
 
 
 
 
 
 to  CTG  monitoring  with  a  number  of  elements  in  relation  to  the  management  of  CTG 
interpretation and escalation. We have planned for a number of actions going forward in order 
to ensure that we have a robust process in place in respect of these. Please see the attached 
excel spreadsheet for full sight of the CTG action plan, some of which are detailed above and 
the work is ongoing. 

Lastly,  I  note  your  area  of  concern  relating  to  why  100  maternity  units  in  the  country  are 
following the wrong guidelines in relation to managing fetal heart rate morning following the 
 at the Inquest.  I am aware that the Department 
evidence you heard from 
of Health and Social Care will be responding to you on this point however I hope the contents 
of this letter demonstrates the relevant actions that the Trust have taken in relation to this. 

I hope this letter demonstrates the commitment of East and North Hertfordshire NHS Trust to 
ensuring that  we  have  learnt from  this tragic  incident  and gives  you the assurance that  we 
have  put  a  number  of  measures  in  place  to  mitigate  against  the  risk  of  a  recurrence.    Our 
Maternity team are committed to providing the best possible care for women in our area and 
we continually strive to improve the services available. 

Yours sincerely 

Chief Executive 

C.C 

, Acting Deputy Director of Nursing and Quality, NHSE/I 

, Chief Nurse, Herts and West Essex ICS 

Chief Executive:  

   Trust Chair: