Hurrun Maksur

Royal College of 
Obstetricians & 
Gynaecologists 

• 

Miss Nadia Persaud 
Her Majesty's Coroner 
East  London 
Walthamstow Coroners Court 
Queens Road 
Walthamstow, E17 8PQ 

4 March 2022 

Dear Miss Persaud 

Re:  Regulation 28 Report into the death of Mrs Hurrun Maksur 

Thank you for your Regulation 28  Report to Prevent Future Deaths following the inquest 
into the death of Mrs Hurrun Maksur dated 15th  December 2021. We would like to begin by 
extending our sincere and  heartfelt condolences to Hurrun's family for their deep loss. We 
recognise and  respect the narrative conclusion from the inquest. 

In your report you  raised two concerns: 

1.  Concern  was raised during the course of the inquest in  relation to the reference to 

the FAST scan.  It  was considered that reference should be to a point of care 
ultrasound scan,  as trauma is not necessary a pre-condition for the scan to take 
place. 

2.  That obstetricians do not receive specific training to identify intra-abdominal 

bleeding'. 

In  order to provide a full response,  we have been  in  touch with colleagues at The 
Association of Early Pregnancy Units, as  well as  with Senior College Officers and our 
Curriculum Committee (responsible for core training in Obstetrics and  Gynaecology) 

Screening for ectopic pregnancy is  a mandatory part of the ultrasound assessment in early 
pregnancy. Anyone undertaking a scan  in early pregnancy must check for a potential ectopic 
pregnancy. This is  specifically stated in  our advice regarding ultrasound training: ultrasound­
scan--guidance-vfinal.pdf (rcog.org.uk) 

Most of the routine scans  in early pregnancy within antenatal services are carried out by 
ultrasonographers rather than consultants or trainees in Obstetrics and Gynaecology (O&G}. 
Excluding ectopic pregnancy is  a routine part of the first scan,  although the scan  is  not 
usually carried  out until 11-12 weeks' gestation. In  clinical practice,  nearly all  patients with 
ectopic pregnancies will have presented to gynaecology emergency services  by the time 
that scan  is  due to be  undertaken and  it is  rare for an  ectopic pregnancy to be diagnosed 
that late in  pregnancy. 

Royal College of Obstetricians and Gynaecologists, 10-18 Union Street,  London SE 1 1 SZ 

T:  +4-1 (0) 20  /772 6200  W: rcog.org.uk 

S: @RCObsGyn 

':I'  • 

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 Royal College of 
Obstetricians & 
Gynaecologists 

• 

Within gynaecology emergency services, scanning is  undertaken by a mixture of 
ultrasonographers trained by and working within radiology departments and  O&G  doctors; 
in any case they are all trained to check that the pregnancy they are  observing is 
intrauterine. However, there are very few, if any, Trusts in the UK with emergency 
gynaecology service provision which relies on  ultrasonography being carried out solely by 
O&G  doctors. 

The assessments required of trainees within our core curriculum  involve transabdominal 
scanning in  early pregnancy. The College has had much discussion about transvaginal 
scanning as  part of the core and  basic curriculum,  but because  most ultrasound 
examinations are carried out by ultrasonographers we subsequently did not put this into the 
curriculum as  a specialist skill.  If a woman  presents with a ruptured ectopic pregnancy, the 
expectation would be that the woman would be seen  as  an  emergency, a clinical 
assessment made and  a decision about urgency taken. The woman can  be taken to theatre 
without a scan  if urgent surgery is thought to be  life-saving. This  is  outlined in  our Capability 
in  Practice (CiP)  9 where we state that trainees should "Formulate an appropriate and 
individualised management plan taking into account a person's preferences and the urgency 
required." 

Because  of the way that ultrasound services are set up in the UK i.e. there is no clinical  need 
(and  sometimes no opportunity) for O&G  doctors to routinely perform early pregnancy 
scans,  RCOG  educators have  not sought to train all  our junior doctors to independent 
competence level and  have added the following caveat to the curriculum: 

'Completion of the two mandatory transabdominal ultrasound skills does not imply that a 
trainee is automatically ready for independent practice in  diagnostic ultrasound 
(particularly in  out of hours unsupervised clinical settings). Care should be taken in 
delegating decisions about clinical management of patients to trainees who have 
completed only the mandatory modules (particularly where management relies on the 
ultrasound findings).  The expected utilisation of ultrasound skills, both within and out of 
hours should be determined and agreed by the local ultrasound supervisor in the context 
of local protocols for ultrasound scanning.' 

With reference to the second  concern, transabdominal ultrasound scan  in the first trimester 
is  utilised to confirm the intrauterine site of the pregnancy and the presence of a feta I 
heartbeat. It is  routine and  part of the training to note how much free fluid is  present in the 
pelvis, and whether the fluid  identified resembles blood or peritoneal fluid. The  implications 
are that if the pregnancy is  not intrauterine, you  would look for a bleeding ectopic 
pregnancy. We acknowledge that in the responses  raised there was a concern about the 
timely recognition of intraperitoneal bleeding. Bleeding from a ruptured, or more commonly 
leaking, ectopic pregnancy is  often slow and the blood clots in the peritoneal cavity. This 
means that there is  not much  'free fluid' and the clotted blood looks very similar to loops of 
bowel. A young fit woman may deteriorate at a late stage and  may have an  abdomen full of 
clotted blood that is  missed on  a portable transabdominal scan  looking for fluid. This  is  a 
different situation from identifying intra-abdominal  bleeding later in  pregnancy. 

Roya I College of Obstetricians and Gynaecologists, 10-18 Union Street, London SE 1 1 SZ 

T:  +44 (0)  20 7772 6200  W: rcog.org.uk 

S: @RCObsGyn 

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 Royal College of 
Obstetricians & 
Gynaecologists 

Later in  pregnancy, or in the situation where the gestational age  is  unknown (such as  a 
concealed  pregnancy) scans  may be  undertaken by a variety of personnel but in most cases 
within an  obstetric setting such  as on  labour ward or a gynaecology setting such as  an  early 
pregnancy unit, this would be experienced  ultrasonographers trained and  working within 
radiology departments. 

' 

RCOG  is  supportive of the guidance from MBRRACE UK (2019) wh ich  states:  Women of 
reproductive age,  presenting to the ED  collapsed,  in  whom a pulmonary embolism is 
suspected, should have a Focussed Assessment with Sonography in  Trauma (FAST) scan  to 
exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in  the 
presence of anaemia. 

In A&E,  abdominal scanning is  usually performed by doctors working within the A&E 
department who are trained to look for intra-abdominal bleeding; for example in cases of 
abdominal trauma, ruptured arterial aneurysms etc.  It is very rare  indeed for an  obstetric 
doctor to be carrying out such  a scan  within an  A&E  department and  most obstetric doctors 
would go through their whole hospital career without being asked to perform an  ultrasound

I!  in these circumstances.  Because of the lack of opportunities within routine O&G  clinical 

practice,  it would not be feasible to train all  our doctors to be able to do this reliably even 
using simulation . Not only would it be  difficult to organise train ing, they would not be  able 
to retain their skills by regular practice - unlike doctors working in A&E . It would be  better to 
focus training efforts on those doctors who perform this sort of scan  (a  FAST scan)  on  a 
routine basis. 

Whilst the O&G  doctors should clearly be  part of the team making decisions about the care 
of a collapsed  pregnant woman, they are likely to be the least experienced in terms of 
performing the FAST scan. 

It is  our intention to engage in  discussions with educators from the Faculty of Emergency 
Medicine and the Royal  College of Radiologists to reinforce the need to check for intra­
abdominal bleeding before anticoagulating a collapsed  patient. 

Additional information on training 
In  addition to the above, the following information provides further clarity on  our training in 
this area: 

As  above in point 1,  competencies are  outlined in CiP  9:  The  doctor is  competent in 
recognising and managing emergencies in  gynaecology and early pregnancy' (pages 19 and 
20  in the Definitive Document for the Core  Curriculum). 

There are further competencies outlined in CiP  11: The  doctor is competent in  recognising, 
assessing and managing emergencies in  gynaecology and early pregnancy' (pages 23-25 in 
the Definitive Document for the Core Curriculum). 

Roya I College of Obstetricians and Gynaecologists, 10-18 Union Street, London SE 1 1 SZ 

T:  +44 (0)  20 7772 6200  W: rco g.o rg .uk 

S: @RCObsGyn 

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 Royal College of 
Obstetricians & 
Gynaecologists 

It is  expected that O&G trainees are  able to independently perform Transabdominal 
ultrasound examination or early pregnancy, as confirmed by three summative competent 
OSATS (page 44,  Definitive Document for the Core Curriculum}. 

' 

The detailed knowledge criteria for CiP  9 appears in  knowledge areas 3 and  13 in our 
MRCOG  membership examination: 
MRCOG  knowledge requirements: Area  3 - core surgical skills 
MRCOG  Knowledge requirements : Area  13 - early pregnancy care 
The  detailed knowledge criteria for CiP  11 appears in  knowledge areas 10, 11, 12, 14 and 15. 

We hope that this provides further clarity on the above training queries and demonstrates 
that the RCOG  is  committed to improving the standard of care  provided for women and 
working collaboratively with others to prevent tragedies like this in the future. 

Yours sincerely, 

Vice  President, Royal  College of Obstetricians and Gynecologists 

Vice  President for Education, Royal  College of Obstetricians and Gynaecologists 

Chief Executive,  Royal  College of Obstetricians and  Gynaecologists 

Roya I College of Obstetricians and Gynaecologists, 10- 18 Union Street, London SE 1 1 SZ 

T:  +44 (0)  20 7772 6200  W:  rcog.org .uk 

S: @RCObsGyn 

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Council UK 

Nadia Persaud 

Senior Coroner 

Walthamstow Coroners Court 

Queens Road 

Waltham stow 

E17 8QP 

31  January 2022 

Dear Ms Persaud, 

Re:  Inquest touching upon the death of Mrs Hurrun Maksur - Preventing Future Deaths Report 

Thank you for your request dated 15 December 2021 . "The Resuscitation Counci\ UK jRCUK) has 

reviewed the Regulation  28  (Preventing  Future  Deaths)  Report and case summary prov·1ded . 

The RCUK has been specifically asked to incorporate the MBRRACE UK 2019 Guidance that states: 

'Women of reproductive age,  presentrng to the ED' cottapsed,  in w'norn a pdrmonaryemDo'rism is 

suspected,  should have a Focussed Assessment with Sonography in  Trauma {FAST)  scan to exclude 

intra-abdominal bleeding from a ruptured ectopic pregnancy especially in  the presence of anaemia.• 

The RCUK response below has been led by Dr

, Chair of the ALS Subcommittee and 

Subcommittee members Dr

 and Dr

. 

1.  The RCUK updates its guidelines on a regular basis using a process that is accredited by the 

National  Institute for Health and Care Excellence (NICE). The most recent update was in May 2021. 

With regards the use of sonography (ultrasound is the mare common\y used term), the \atest 202--\. 

the RCUK guidelines include: 

a.  A greater emphasis on the use of ultrasound during Advanced life Support (ALS) to identify 

and treat reversible causes of cardiac arrest 1rus appUe.~ ID a\\. cardi.ac:. ;yews ~~j_-11-,;;,\. 

for the pregnant patient. This is specifically mentioned in the reversible causes part of t'ne 

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ALS algorithm. See https://www.resus.orq.uk/library/2021-resuscitation-guidelines/adult­

advanced-life-support-guidelines 

b.  Specific guidelines for cardiac arrest rn  the pregnant patient induding •identify and treat 

reversible causes (e.g.  haemorrhage). Focused ultrasound by a skilled operator can be used 

to identify reversible causes and may also be used to assess if a fetal heart rate is present.• 

See https://www.resus. orq. uk/library/2021-resuscitation-qu idel ines/special-ci rcumstances-

g uidel ines 

2.  The RCUK Advanced Life Support Manual (8th Edition, May 2021) includes the following regarding 

haemorrhage: 

Reversible causes of collapse and cardiac arrest in pregna1ncy 

Look for reversible causes using the 4 Hs and 4 T s approach. Abdominal ultrasound by a skilled 

operator to  detect possible causes during cardiac arrest can be!  useful. 1t can also permit an 
evaluation of feta/ viability,  multiple gestations {twins) and plaCEmtal localisation.  nshou1d not 
however delay treatments.  Specific reversible causes of collapse or cardiac arrest in pregnancy 

include: 

Haemorrhage 

This  can occur both antenatally and postnatatly. Causes include ectopic pregnancy, placental 

abruption, placenta praevia, abnormal placentation {incretal percreta) and uterine rupture . 

Maternity units should have a massive haemorrhage protocol. Treatment is based on the ABCDE 

approach.  The  key step is to stop the bleeding. 

3.  RCUK Advanced Life Support Manual {8th Edition, May 2021) includes the  following regarding 

pulmonary embolism in pregnancy: 

Pulmonary embolism 

Pulmonary embolism causing cardiopulmonary collapse can present throughout pregnancy . CPR 

is started with modifications as necessary. The use of fibrinolytic therapy needs considerable 

thought,  particularly if a peri-mortem caesarean section is beintJ considered {see below).  If the 

diagnosis is suspected and maternal cardiac output cannot be restored it should be given. 

4.  The RCUK ALS subcommittee's opinion is that the issues raised '.Dy the MBBRACE report and the 

Inquest are addressed in the most recent RCUK guidance and teaching materials. Speciflca\\y: 

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a.  Firstly, RCUK is mindful that its guidelines address allcardiac arces~arnHna'i..ma\ema\ 

cardiac arrests make up a very small proportion these arrests. \n addition the specia\ist skins 

and equipment required for ultrasound during resuscitation are not a\ways immediate\y 

available in all settings. Any changes therefore need to be proportionate and recognise t'ne 

risks of delaying time critical treatments such as flbrino\ysis "in patients with a suspected PE. 

b.  Active major bleeding (haemorrhage) is a contraindication for thrombolytic {frbrino\ytic) drugs 

regardless of the cause of bleeding or the patient group. This risk of bleeding with fibrinolytic 

drugs (which dissolve clots and prevent clotting) shou\d a\ready be known to those who use 
them.  The section of the RCUK Advanced tife SapportManua~ tath E<:Mi'arr,  Ma,r2fl~1ns'ls 
contraindications to fibrinolytic therapy - active internal bleeding is an absolute 

contraindication. 

c. 

In addition to an ectopic pregnancy, there are a number of causes of co\\apse from b\eeding 

in  the pregnant patient and these are highlighted in the current teaching materials. 

d.  There is already a strong emphasis on the use of u\trasound to look for reversible causes 

including haemorrhage in  RCUK guidelines and teachin9- ma~-er1a\.c;, ror B\\. cau~s.. .  ~~4:~ 
arrest including cardiac arrest during pregnancy. 

5.  To address the variance with the MBRRACE UK 2019 guidance, RCUK will further emphasise the 

need to exclude major bleeding as the cause of collapse before giving iibrino\ytic drugs tor suspected 

PE  in  pregnancy. We will also consider other teaming from this case. "The following areas wll'I 'oe 

reviewed and updated as  necessary: 

a.  Next print run of RCUK Advanced Life Support Manua\ (8th Edition, May 2021). 

b.  Teaching materials on  the ALS course concemlng pregrrancy. 

c.  Obstetric Cardiac Arrest Quick Reference Handbook in col\aboration with MBBRACE and the 

Obstetric Anaesthetists Association. 

6.  The RCUK will share this response with: 

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enquiries@resus.org.uk 

5th Floor, Tavistock House North 

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 g Resuscitation 

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a.  The Royal College of Obstetricians and Gynaecologists. arul1 \ia~e. '44\\'n 'me.~_sw..~~9--­

whether further updates are required. 

b.  The ALSG that oversees the Managing Medical and Obstetric Emergencies and "Trauma 

(mMOET) course. 

Yours Sincerely 

Director of Clinical and Service Development 
On  behalf of Resuscitation Council UK 

resus.org.uk 

enquiries@resus.org.uk 

5th Floor, Tavistock House North 

Tavistock Square, London WClH 9HR 

Registered Charity Number 1168914