Finley May

Professor Paul Marks  
East Riding and Hull Coroner’s Service 
The Guildhall  
Alfred Gelder Street  
Hull  
HU1 2AA 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

20 September 2023 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Finley Austin May who 
died on 16th March 2021.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26 July 
2023 concerning the death of Finley Austin May on 16th March 2021. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Finley’s parents and family. NHS England are keen to assure the 
family and the coroner that the concerns raised in your Report been listened to and 
reflected upon.  

Your Report raised that the use of Kielland’s rotational forceps resulted in high spinal 
cord injury leading to the death of Finley. During the course of the inquest, evidence 
was heard that the use of these obstetric forceps can facilitate delivery from the mid-
pelvis in cases of malrotation, asynclitism and where the lie is occipito-transverse or 
occipito-posterior, and that this is a well-accepted practice.  

The Royal College of Obstetricians and Gynaecologists (RCOG), who I note you have 
also  addressed  your  Report  to,  published  clinical  guidance  to  support  obstetricians 
and  gynaecologists  to  deliver  high  quality  care.  Their  guidance  on  evidence-based 
recommendations for assisted vaginal birth can be found here: Assisted Vaginal Birth 
(Green-top  Guideline  No.26).  Following  several  adverse  incidents,  in  June  2023, 
RCOG  posted  an  update  to  this  guidance,  encouraging  clinicians  to  review  and 
consider their obligations around the use of Kielland’s rotational forceps. The update 
states  that  rotational  births  using  Kielland’s  forceps  should  only  be  performed  by 
experienced operators or under the direct supervision of an experienced operator. An 
ultrasound assessment of the foetal head position prior to the application of the forceps 
is also advised.  

NHS England accepts RCOG’s advice that delivery using Kielland’s forceps may be 
appropriate in certain clinical situations. As part of their safety governance standard 
operating practices, NHS Trusts providing maternity care should ensure that:  

•  Any clinician leading a delivery using Keilland’s forceps should be trained and 
competent  in  their  use  and  be  aware  of  all  the  risks  associated  with  the 
technique. 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 •  Any  clinician  conducting  an  operative  vaginal  delivery  should  assess  the 

advantages and disadvantages of the available delivery techniques. 

•  Any clinician conducting an operative vaginal delivery should ensure that the 
pregnant woman has been made aware of the delivery options available to her 
and the material facts as part of the consent process.  

NHS England’s regional members of the Regulation 28 Working Group (please see 
penultimate  paragraph)  will  be  asked  to  communicate  with  their  Integrated  Care 
Boards to ensure that all Trusts are fully aware of the updated guidance.  

Birmingham University are also in the process of recruiting to the ROTATE trial. The 
randomised trial will look at manual versus instrumental rotation of the foetal head in 
malposition at birth. The trial will evaluate the differences between the two rotational 
techniques  and  the  clinical  outcomes  for mothers and  babies,  and  whether manual 
rotation reduces the risk of severe maternal perineal trauma. The results of this trial 
will be carefully reviewed.  

I would like to provide further assurances on national NHS England work taking place 
around the Reports to Prevent Future Deaths. All reports received are discussed by 
the Regulation 28 Working Group, comprising Regional Medical Directors, and other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around preventable deaths are shared across the NHS at both a national 
and regional level and helps us pay close attention to any emerging trends that may 
require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely,   

National Medical Director

Professor Paul Marks  
Her Majesty’s Senior Coroner for Kingston Upon Hull 
The Guildhall 
Alfred Gelder Street 
Kingston Upon Hull 
HU1 2AA 

21 September 2023 

Dear Sir, 

Re: Finley Austin May – deceased 

Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of 
Finley Austin May dated 27 July 2023. 

The loss of a baby is a devastating tragedy for parents, the wider family, and healthcare professionals 
involved. We would like to begin by extending our deepest and heartfelt condolences to Finley’s family for 
their deep loss. 

This response has been developed following input from members of the RCOG Patient Safety Committee 
and Senior Officers of the College.  

We recognise and respect the narrative conclusion from the inquest that Finley Austin May died as a result 
of a spinal cord injury caused by the use of Kielland’s forceps during delivery with malposition and 
prolonged labour.  

We also recognise the matters of concern, in particular 4 and 5: 

(4) Continued use of Kielland’s forceps may be the most appropriate way to manage this obstetric 
problem but there should be increased awareness of complications associated with its use and guidance 
issued about the minimum number of cases per annum needed to maintain skill levels coupled with 
guidance for training. 

The O&G training curricula follow the GMC’s ‘Excellence by Design’ principles and have been mapped to 
the Generic Professional Capabilities. The curricula are competency based, rather than ‘number’s’ based, 
as such the College does not recommend a minimum number of cases per annum.   

Trainees attaining Certificate of Completion of Training (CCT) will be skilled in managing the labour ward 
independently and managing the acute gynaecological on-call service. They will have expertise in practical 
procedures related to the clinical care of women and will be expert communicators with strong 
interpersonal skills, strong emotional intelligence and adept at the management of sensitive situations. 

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 These areas ensure that doctors in training and beyond CCT can provide safe care whilst working in a range 
of challenging and diverse work environments, balancing acute and non-emergency service provision.  
The College’s programme of assessment encompasses the integrated framework of exams, assessments in 
the workplace and judgements made about a learner during their approved programme of training. The 
emphasis is on the importance of professional judgment in making sure learners have met the learning 
outcomes and expected levels of performance set out in the approved curricula. It also focuses on the 
learner as a reflective practitioner with emphasis on acting within one’s own expertise to seek support in 
less familiar circumstances. Assessors will make accountable, professional judgements on whether 
progress has been made to support decisions on progression and satisfactory completion of training. 

As stated above, with regards to training, The College takes a competency versus number per year 
approach to continuous professional development requirements. The College supports the GMC’s Good 
Medical Practice guideline (points 7-10) which state that for doctors (supported by the organisations 
employing them):  

7. You must be competent in all aspects of your work, including management, research and 
teaching.  

8. You must keep your professional knowledge and skills up to date.  

9. You must regularly take part in activities that maintain and develop your competence and 
performance.  

10. You should be willing to find and take part in structured support opportunities offered by your 
employer or contracting body (for example, mentoring). You should do this when you join an 
organisation and whenever your role changes significantly throughout your career.  

For consultant practitioners and specialists these would be assessed at annual appraisal. For doctors in 
training they would be assessed annually during their training assessment by the Deanery. In both 
instances any serious incidents need to be documented to enable review against the GMC Good Medical 
Practice guidance and the RCOG training matrix. The RCOG training matrix presents a progression from 
supervised practice to independence, as doctors in training accumulate technical skills and experience.  

To support our membership in being compliant with the regulators and fulfil these requirements the 
College hosts a range of training opportunities including an annual training course RCOG Operative Birth 
Simulation Training (ROBuST). The aim of ROBuST is to provide hands-on practice in all methods of 
operative vaginal birth (both non-rotational and rotational) to facilitate the achievement of the OSATS 
(objective structured assessment of technical skills) competencies on the RCOG Training matrix. These 
promote an evidence base to demonstrate, develop and maintain safe clinical practice and the means to 
record and validate experience. 

(5) If NHS trusts have abandoned the use of Kielland’s forceps, clear guidance should exist about 
alternative methods of managing malrotation and asynclitism. 

Kielland’s forceps are currently recognised as an option to assist rotational vaginal birth in our current 
guidance on Assisted Vaginal Birth. The risk of cervical spine injury using Kielland’s is extremely low, but 

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 any such serious injury is taken very seriously by the RCOG. We added a safety statement in relation to use 
of Kielland’s forceps to our guidance on the webpage in June 2023, which states the following: 

Following several recent adverse incidents, the College wishes to remind clinicians of their key obligations 
to promote the safe use of Kielland's rotational forceps. 
Assisted vaginal birth promotes benefits to both mother and the baby when used appropriately and safely. 
We have no doubt that clinicians use Kielland’s forceps with a high degree of caution, and respect the skill 
and expertise required to facilitate a safe birth. Misuse or incorrect application of Kielland’s forceps can, 
however, result in serious complications for both mother and baby. 

Rotational births using Kielland’s forceps should only be performed by experienced operators or under the 
direct supervision of an experienced operator. The operator is required to define fetal head position and 
identify the position of the occiput correctly, in order to safely undertake a rotational birth. In this regard, 
an ultrasound assessment of the fetal head position prior to application of forceps is more reliable than 
clinical examination and is advisable. 

While ultrasound scan is not directly mandated prior to all assisted births, it should be noted that recent 
concerns arose following inaccurate assessment of the fetal head position by clinicians prior to starting the 
procedure. Procedure should also be discontinued where rotation is not easily achieved with gentle 
pressure, after confirming correct application. 

RCOG Green-top Guideline No. 26 on Assisted Vaginal Birth, published in 2020, provides the evidence-based 
recommendations to support practitioners around use of instruments for assisted vaginal births, and 
promotes support for the availability of intrapartum ultrasonography for clinicians in their daily practice. 

This area of enquiry is active with nationally funded research ongoing (ROTATE Project 
https://fundingawards.nihr.ac.uk/award/NIHR127818). The RCOG guidance on Assisted Vaginal Birth will 
be updated once this project has concluded.  

The RCOG is committed to improving the standard of care provided for women by working collaboratively 
with all stakeholders, including Coroners.  

Yours sincerely, 

CEO Royal College of Obstetricians and Gynaecologists 

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