Alfie Hinton

Chief Executive’s Office  
Airedale General Hospital 
Skipton Road  Steeton 
KEIGHLEY  West Yorkshire 
BD20 6TD 
Telephone:  01535 294801 
Email: 

fa/mn/hfg 

24 January 2025 

STRICTLY PRIVATE & CONFIDENTIAL 

Ms Charlotte Keighley  
H M Assistant Coroner for West Yorkshire  
(Western Coroner Area) 
H M Coroner's Office 
City Courts 
The Tyrls 
BRADFORD  
West Yorkshire  BD1 1LA 

Dear Ms Keighley 

INQUEST TOUCHING UPON THE DEATH OF ALFIE HINTON  

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 2 December 2024, 
which you sent following the inquest touching the death of Alfie Hinton.  

Firstly, I wish to convey my sincere condolences to Alfie’s parents and family for the loss of Alfie.  

In advance of the Inquest, the Trust’s response to this case was as follows: 

-  We reported the case to the Healthcare Safety Investigation Branch (‘HSIB’) on 16 May 2019 
in  order  that  it  may  undertake  an  independent  investigation  into  the  circumstances  of  the 
case and to identify learning and propose any safety recommendations; 

-  With knowledge that the HSIB could take up to nine months (at the time) to provide a report 
to support learning, we undertook our own concurrent, internal investigation in case any more 
urgent actions were required and we produced an Action Plan as part of that process. 

-  On receipt of the HSIB report in December 2019, we accepted its recommendations in full 

and made revisions to the Action Plan in response, and implemented the same; 

-  We carefully considered the independent expert report which the Coroner had obtained from 
Professor Draycott, Consultant Obstetrician and also accepted his recommendations in full. 

In the Regulation 28 report you have raised the following concerns: 

1) During the course of the Inquest, I could find no evidence of how or if the maternal risks were 
assessed  following  her  admission,  nor  how  the  level  of  risk  posed  by the  level  of  bile  acids  was 
communicated  to  those  tasked  with  prioritising  those  patients  awaiting  induction  of  labour  and 
therefore the allocation of staffing and resources. This is further reflected in the 39 minute delay in 
CTG monitoring and the fact that at the point Bradycardia was noted, the initial assumption from staff 
was that there was an issue with the monitoring equipment, there being little awareness of the risks 
already  present,  which  contributed  to  delays  in  expediting  delivery.  These  facts  gives  rise  to 
concerns in respect of the way in which information is gathered and shared within the Maternity Unit 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 2 

and in particular how risk is recorded and communicated between all of those involved in providing 
intrapartum care.  

2) During the course of the Inquest, I heard evidence about the difficulties in communication between 
the  Consultant  Obstetrician  and  Consultant  Anaesthetist,  with  delays  being  caused  by  several 
attempts  being  made  at  siting  spinal  anaesthetic,  against  the  advice  of  the  Obstetrician  and  the 
wishes of the patient, causing distress to staff and patient alike. I heard no evidence of any policy 
that  provided  direction  or  guidance  in  circumstances  such  as  this.  This  gives  rise  to  concerns  in 
respect of communication, ongoing risk assessment and an absence of local policy in respect of the 
approach to be taken in such time critical situations. 

Please  be  reassured  that  the  Board  are taking  the  receipt  of  a  Regulation  28  very  seriously  and 
understand the importance of providing safe patient care. In response to these outstanding concerns 
and on receipt of the Regulation 28 PFD, the executive team have led a further review to assist me 
with compiling this response, comprising: 

1. 

2. 

3. 

, Executive Medical Director (interim); 

, Executive Director of Corporate Affairs (interim); and  

, Chief Nurse (interim). 

The  clinical  leads  and  other  senior  personnel  from  the  various  directorates  have  also  been  fully 
involved in this review to support this response. 

In response 

Concern 1: 

The review has confirmed that it is the admitting obstetric consultant’s responsibility to determine the 
clinical condition of the patient and the risks posed by any clinical condition/diagnosis to both mother 
and  the  unborn  baby  and  to  implement  a  management  plan  which  accords  with  those  assessed 
risks.  

The admitting obstetric consultant would need to determine whether the unborn baby needed to be 
delivered more urgently by way of caesarean section or whether it was appropriate to proceed to 
induction of labour (“IOL”) (or other mode of delivery). The decision making around IOL is supported 
by the Trust’s guideline ‘Induction of labour (incorporating management of pre-labour spontaneous 
rupture of labour at term)’ [pages 1488 - 1509 of the Inquest bundle]. 

In  Mrs  Hinton’s  case,  on  08.05.19,  it  was  promptly  recognised  by  the  admitting  Consultant 
Obstetrician  that  her  bile  acids  were  very  significantly  elevated  and  that  she  was  suffering  from 
Obstetric Cholestasis.  

The Trust had in place at the time a guideline to support the diagnosis and management of Obstetric 
Cholestasis (‘Obstetric Cholestasis (Intrahepatic cholestasis of pregnancy)’) [pages 1576 – 1588 of 
the Inquest bundle]. Mrs Hinton’s bile acid level put her in the ‘Severe ICP’ category, indicating that 
there existed a still birth risk that was higher than the background risk.  

In Mrs Hinton’s case, following diagnosis, it was recognised that treatment needed to be initiated in 
the form of Ursodeoxycholic Acid (UDCA), with definitive treatment ultimately being delivery of the 
baby. It was not considered necessary to treat the case as an emergency and thereby proceed to 
caesarean section at that time; a view that is supported by HSIB and 
. At the point 
of  admission,  the  Consultant  Obstetrician  had  hoped  that  IOL  would  be  able  to  commence  the 

Associated Teaching Hospital of the 
University of Leeds School of Medicine 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 3 

following morning (09.05.19) if circumstances (both ward activity and acuity) permitted, following two 
doses of steroids which were to occur 12 hours apart according to guideline. 

As to the specific issue of how risk factors are communicated, every expectant mother admitted to 
the maternity unit would be under the care of an obstetric consultant and/or midwife and those 
clinicians would bear responsibility for knowing the patient’s history and presentation and to review 
and complete the patient’s record, which would contain all such information.  

Furthermore, in evidence to the Inquest it was explained that each patient is subject to a structured 
discussion at handover between day shift and night shift teams (and so twice per day), including 
details  of  the  patient,  the  reason  for  their  admission,  their  diagnosis  (where  applicable), 
comorbidities, and proposed plan for care and delivery, including whether that is by way of planned 
caesarean section, induction of labour or any other mode of delivery, so that the whole team are 
aware of the position.  

In addition to handover, where the patient is subject to consultant led care, the obstetric consultants 
hold twice daily ward rounds, which is typically attended by the Consultant, junior doctors, Labour 
Ward  Coordinator,  allocated  midwife  and  the  obstetric  anaesthetist  (when  available  or  where 
necessary).  Each  patient  is  discussed  at  this  multi-disciplinary  ward  round  in  further  detail  to the 
information handed over at the morning or evening handovers, specifically addressing the reason 
for IOL and urgency.  

The Labour Ward Coordinator has responsibility for the oversight of all expectant mothers and is 
responsible for managing the workload of all members of the midwifery team and prioritising clinical 
activities. The obstetricians also have responsibility for reviewing the patient, their results etc and 
advising on priority. Priority for IOL is an MDT decision.  

The  Labour  Ward  Coordinator  reassesses  the  full  unit  4-hourly  and  (amongst  other  information) 
records  the  available  staffing  resource,  patient  numbers  and  acuity.  At  the  time  of  this  case,  this 
information was recorded within the ‘National Patient Safety Agency Intrapartum Score Card’; a 
national tool used in these circumstances.  

In addition, as given in evidence at the Inquest, the Labour Ward at the time held an  Induction of 
Labour Diary, which would detail all patients planned for IOL. The Labour Ward Coordinator would 
make an assessment of activity and acuity of the unit (at least 4-hourly as above) based on the Score 
Card data and make a decision as to whether any additional patients at home (details of whom would 
be  included  in  the  Induction  of  Labour  Diary),  could  be  invited  into  the  unit  to  prepare  them  for 
induction/section.  

In terms of the communication of each patient’s clinical condition and as an aid to prioritisation, the 
Labour Ward Coordinator’s office also held a whiteboard, on which all patients were detailed, which 
was a further tool to assist with prioritisation.  

The patient’s clinical records are also central to communicating details of the clinical condition as 
between clinicians. It is noted that in Mrs Hinton’s case: 

1.  at the head of the handwritten midwifery records (pages 743, 745, 747, 749, 751, 753, 756, 
759, 761, 763 of the inquest bundle) each page is clearly marked at the head of the page as 
“Antenatal risks present √ ” and “↑ Bile Acids”; 

2.  the specific value of bile acids is also recorded on the ‘SBAR Maternity Handover’ records at 
pages  775  and  776  of  the  inquest  bundle,  to  which the  allocated midwife  would refer  and 
complete; 

3.  the specific value of bile acids is also recorded within the clinical record at page 756; 

Associated Teaching Hospital of the 
University of Leeds School of Medicine 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4 

4.  the specific value of bile acids is also recorded within the SystmOne records at page 957; 

and 

5.  the specific value of bile acids would also be held within the Clinical Biochemistry records to 
which the whole team had access (page 867 of the inquest bundle) – the admission value of 
149 umol/L (which dropped dramatically to 35 umol/L by 10.05.19 – page 877 and 6 umol/L 
by 11.05.19 – page 883). 

In effect at the time of this case was the Trust Guideline ‘Handover of Care on Site – Maternity Unit 
Maternity  Services’  which  details  expectations  regarding  handover  of  patients  between  clinicians 
and necessary communications and records surrounding this process. The guideline applies to all 
maternity staff and in the following situations: 

•  At midwife and multidisciplinary handover at change of shift 
•  Midwife to doctor on ward round/raising concerns 
•  From midwife to midwife at change of shift 
•  Midwife to midwife from/to antenatal/postnatal ward to labour ward staff 
•  Midwifery and nursing staff on transfer to/from ICU/HDU, theatre and general ward. 

Included is the SBAR (Situation, Background, Assessment, Recommendation) communication tool 
which  is  fully  embedded  and  utilised  as  an  effective  means  of  transfer  of  clinical  information  as 
between health professionals and is included and completed within the patient’s record [pages 770-
776 of the Inquest bundle].  

We also observe at this stage that LW Coordinator, BB, gave evidence to the inquest to the effect 
that she was fully aware of Mrs Hinton and her clinical condition throughout the day shift of 09.05.19 
and that she was communicating with the Obstetric Consultant with regards to patient acuity on the 
unit to determine the point at which it was safe to offer Mrs Hinton IOL, which was agreed shortly 
after 18:00 hours on 09.05.19. 

The  Coroner’s  independent  expert, 
  provides  evidence  that  “There  was  delay 
commencing the IOL related to unit level activity. This is a common issue in current practice across 
the  UK  and  I  consider  that  it  was  reasonable  to  have  delayed  the  IOL  until  the  unit  could 
accommodate Mrs Hinton”.  

It was however explained in evidence that as a result of the events in this case and in response to 
the 
the  Healthcare  Safety 
circumstances  of  this  case,  the  Trust  has  developed  and  implemented  an  Induction  of  Labour 
Prioritisation Proforma, to highlight risks and associated priority of women attending for induction 
of labour. The Trust supplied the Coroner with the proforma and this details the following guidance: 

Investigation  Branch 

investigation 

independent 

(‘HSIB’) 

into 

• 

“Women who are booked for induction of labour must be added to the IOL diary by the Labour 
Ward  Coordinator.  As much  information  as  possible should be  provided. Women  who  are 
booked for stat/urgent induction of labour must have the following -: The decision for induction 
of  labour  must  be  discussed  with  the  consultant  on  call.  The  decision  made  and  who 
discussed with must be clearly documented in the obstetric notes. Exceptions being induction 
for postdates (term+7-10) or pre-labour rupture of membranes at term. (Induction of Labour 
Guideline) 

•  A  maximum  of  3  inductions  (2x  CLC  and  1x  MLC)  per  day  can  be  booked  through  the 
Induction suite. Any further inductions must be discussed with the labour ward co-ordinator. 

•  Patients awaiting induction who are residing on ward 21 must be prioritised.  
•  A multidisciplinary discussion should take place before or after the ward round on the Labour 
Ward.  The  prioritisation  form  should  be  completed  at  this  time.  The  initials  of  all  team 
members who are part of this discussion should be written in the column at the applicable 
time. An order should then be made and the order number added to the number column. The 

Associated Teaching Hospital of the 
University of Leeds School of Medicine 

 
 
 
 
 
 
 
 
 
 
 
 
 5 

multidisciplinary review will take place at each ward round or Doctors handover. If a woman 
declines to come in at the time arranged this should be documented in the multidisciplinary 
discussion documentation box. Any woman in these circumstances should remain on the list. 
Any delay in admission should also be added to this box. Prioritisation of the women, who 
are  booked  for  induction  of  labour,  will  be  carried  out  in  terms  of  risk.  Women  who  are 
inpatients and also outpatients should be prioritised during this discussion.  

•  Any delays in induction due to clinical activity should be discussed and agreed with the labour 

ward coordinator and consultant. 

•  Any delays longer than two hours are considered to be a red flag and an Adverse Events 
Form should be completed fully and submitted. This should contain the details of the lady 
who has been delayed. Full explanations should be given to the women by both a Doctor and 
a Senior Midwife. 

•  Completed copies of the form will be left in the LW Managers office and will be available to 

support decision making and provide information in Governance reviews.” 

Process – Induction of Labour Management 

In order to provide you with further assurance as to the current process, and visually present the 
process to aid understanding, we have set out a ‘process map’ which details: 

1.  how patients who are to undergo IOL are managed within the maternity unit at Airedale; 

2.  how the activity and acuity is assessed, monitored and managed each day, including joint 

working with other units within the region; 

3.  the various safeguards in place to ensure escalation and prevent avoidable delays in patients 

proceeding to IOL; and 

4.  the process of prioritisation of all patients by appropriate methodology and MDT assessment.  

We provide the policies/procedures and guidelines which inform this process map to evidence the 
clearly defined structures and systems in place at the Trust today.  

Please see Appendix 1 – Process Map – Induction of Labour 

To draw out a few specific points of relevance to your concern: 

1.  I can advise that the Obstetric Cholestasis Guideline has been further updated to reflect the 
updated  RCOG  green  topped  guideline.  This  included  guidance  on  the  timing  of  delivery 
relating to the specific level of the bile acid results.  The guideline states diagnosis of severe 
ICP would prompt delivery between 35-36 weeks.  Diagnosis of severe ICP after 36 weeks 
would require immediate senior obstetric review and Induction of Labour and the guideline 
now makes this clear.  

2.  The prioritisation process and proforma formalises the process of patient management and 
priority  according  to  individualised  patient  risk  and  provides  a  living  record  of  priority  to 
evidence why one patient is scored above another. It reflects MDT agreement as to priority.  

3.  The development of the Trust’s RAG rating system for IOL based on identified risk factors 
will support the standardisation of prioritisation of IOL cases and will further strengthen this 
process  and  provide  objective  support  for  determining  priority,  although,  ultimately,  the 
clinical expertise of the MDT will take precedence and such tools can only be considered to 
be supportive of clinical decision making.  

Associated Teaching Hospital of the 
University of Leeds School of Medicine 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 2: 

Policy / Guideline 

6 

In effect at the time of this case, the Trust’s ‘Anaesthesia for Category 1 Lower Segment Caesarean 
Section  (LCSC)  guideline’  (2016)  [pages  1589  –  1596  of  the  inquest  bundle]  advised  that  the 
anaesthetist has overall responsibility to decide on the method of anaesthesia.  

The relevant section states: 

“The decision for the type of anaesthesia rests with the obstetric anaesthetist, who will assess 
risk factors in the mother such as a known or predicted difficult airway, or morbid obesity. 
The  safety  of  the  mother  is  paramount.  While  general  anaesthesia  is  usually  the  fastest 
method  to  anaesthetise  a  Category  1  caesarean  section;  it  is  associated  with  increased 
maternal  morbidity  and  mortality.  There  is  also  evidence  (level  3)  to  suggest  general 
anaesthesia  may  increase  the  incidence  of  adverse  neonatal  outcomes.  If  a  regional 
anaesthetic is attempted, it may be appropriate to perform a ‘rapid sequence spinal’. This 
consists of a no-touch spinal technique, consideration of omission of the spinal opioid, limiting 
spinal attempts and allowing the start of surgery before full establishment of the spinal block. 
Oxygen  should  continue  to  be  given  during  preparation  for  and  insertion  of  the  spinal 
anaesthetic. The anaesthetist needs to maintain situational awareness, so that if there is any 
delay  in  establishing  adequate  regional  anaesthesia  (and  providing  there  is  no  contra-
indication  to  general  anaesthesia),  then  conversion  to  general  anaesthesia  should  be 
undertaken.  Conversely,  if  the  risk  of  general  anaesthesia  is  considered  to  be  high,  the 
anaesthetist would  be justified in further attempts at spinal anaesthesia while awaiting the 
arrival of experienced help.” 

The  Guideline  was  revised  post  Alfie’s  case  (March  2020  and  again  in  October  2023)  and  the 
relevant sections (taken from the version created in October 2023) state: 

“When a decision is made to perform a category 1 LSCS, the operating surgeon should inform 
the  obstetric  anaesthetist  as  soon  as  possible,  so  that  they  can  assess  the  patient  and 
prepare  for  anaesthesia  with  minimal  delay.  Clear  communication  is  required  between 
the  operating  surgeon  and  the  anaesthetist  to  convey  the  degree  of  urgency  of  the 
caesarean. The obstetrician should state the required timeframe for delivery, so that 
an  informed  decision  can  be  made  about  the  feasibility  of  attempting  regional 
anaesthesia.  The  mother  and  her  partner  should  also  be  kept  fully  informed  of  the 
situation as this will be a very stressful situation for them.”  

“The decision for the type of anaesthesia rests with the obstetric anaesthetist, who will assess 
risk factors in the mother such as a known or predicted difficult airway, or morbid obesity. 
The  safety  of  the  mother  is  paramount.  Whilst  general  anaesthesia  is  usually  the  fastest 
method  to  anaesthetise  a  Category  1  caesarean  section,  it  is  associated  with  increased 
maternal  morbidity  and  mortality.  There  is  also  evidence  (level  3)  to  suggest general 
anaesthesia may increase the incidence of adverse neonatal outcomes. 

If an effective epidural is in situ, it may be feasible to top this up and different regimes can 
be used for this purpose. If spinal anaesthesia is attempted oxygen should be administered 
during preparation for and insertion of the spinal anaesthetic. The anaesthetist must maintain 
situational  awareness  so  that  if  there  is  any  delay  in  establishing  adequate  regional 
anaesthesia  (and  providing  there  is  no  contra-indication  to  general  anaesthesia),  then 
conversion to general anaesthesia should be undertaken. Conversely, if the risk of general 
anaesthesia is considered to be high, the anaesthetist would be justified in further attempts 
at spinal anaesthesia while awaiting the arrival of experienced help.” 

Associated Teaching Hospital of the 
University of Leeds School of Medicine 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Guideline was further strengthened for the Trust (November 2024) and the relevant sections 
confirm: 

7 

“When a decision is made to perform a category 1 LSCS, the operating surgeon should inform 
the  obstetric  anaesthetist  as  soon  as  possible,  so  that  they  can  assess  the  patient  and 
prepare  for  anaesthesia  with  minimal  delay.  Clear  communication  is  required  between 
the  operating  surgeon  and  the  anaesthetist  to  convey  the  degree  of  urgency  of  the 
caesarean. The obstetrician should state the required timeframe for delivery, so that 
an  informed  decision  can  be  made  about  the  feasibility  of  attempting  regional 
anaesthesia.  The  mother  and  her  partner  should  also  be  kept  fully  informed  of  the 
situation as this will be a very stressful situation for them.  

If the mother requests a general anaesthetic, then this should be done unless  there 
are important safety reasons not to.” 

“The decision for the type of anaesthesia rests with the obstetric anaesthetist, who will assess 
risk factors in the mother such as a known or predicted difficult airway, or morbid obesity. 
The  safety  of  the  mother  is  paramount.  Whilst  general  anaesthesia  is  usually  the  fastest 
method  to  anaesthetise  a  Category  1  caesarean  section,  it  is  associated  with  increased 
maternal  morbidity  and  mortality.  There  is  also  evidence  (level  3)  to  suggest general 
anaesthesia may increase the incidence of adverse neonatal outcomes. 

If an effective epidural is in situ, it may be feasible to top this up and different regimes can 
be used for this purpose. If spinal anaesthesia is attempted oxygen should be administered 
during preparation for and insertion of the spinal anaesthetic. The anaesthetist must maintain 
situational  awareness  so  that  if  there  is  any  delay  in  establishing  adequate  regional 
anaesthesia, i.e if spinal is not achieved within a 5 minutes from the initiation of the procedure 
(and  providing  there  is  no  contra-indication  to  general  anaesthesia),  then  conversion  to 
general anaesthesia should be undertaken. A multi-disciplinary discussion will take place at 
5 minutes from the initiation of the spinal to re-assess the situation and consider conversion 
to general anaesthetic.  Conversely, if the risk of general anaesthesia is considered to be 
high,  the  anaesthetist  would  be  justified  in  further  attempts  at  spinal  anaesthesia  while 
awaiting  the  arrival  of  experienced  help,  but  this  must  include  a  multi-disciplinary  risk 
assessment of the clinical situation.” 

In order to bring about this change in process, the senior leads for obstetrics and anaesthetics agreed 
that if spinal anaesthesia is not successfully sited after 5 minutes of the initiation of the procedure, a 
general anaesthetic should be commenced, provided there are no contraindications.  

The Trust considers this to be an important mechanism to ensure that, as a matter of policy, an MDT 
discussion  takes  place  at  5  minutes  from  attempting  to  site  spinal  anaesthesia  and  that  the 
anaesthetists should covert to general anaesthesia at this point. This should prevent anaesthetists 
from proceeding with additional attempts at spinal anaesthesia where there is MDT disagreement, 
thereby avoiding the delays which occurred in this case. This 5 minute interval is identified as an 
appropriate timescale in consideration of the NICE Decision to Delivery Interval (“DDI”) of 30 minutes 
in Category 1 caesarean section (Clinical Guideline CG132). 

The Trust has further strengthened the Guideline to confirm that where a intrapartum sentinel event 
occurs,  general  anaesthesia  should  be  undertaken  unless there  are  important  safety  concerns;  it 
details the steps to be taken to achieve intra-uterine fetal resuscitation in the case of fetal distress; 
to clarify the roles and responsibilities as between the specialist disciplines and the steps to be taken 
if further spinal anaesthesia is to be considered post the five-minute review.    

Associated Teaching Hospital of the 
University of Leeds School of Medicine 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Process – Category 1 Caesarean Section / Fetal Bradycardia 

8 

In order to provide you with further assurance as to the current process, and visually present the 
process to aid understanding, we have set out a ‘process map’ which outlines: 

1.  the management in respect of fetal bradycardia from the point it is first detected; 

2.  the steps taken to declaring the need for a Category 1 lower caesarean section; 

3.  the steps taken thereafter including: 

a.  transfer to theatre 
b.  MDT CTG re-assessment (and plan of care thereafter) 
c.  decision making regarding anaesthetic choice including roles and responsibilities  
d.  the process for achieving effective anaesthesia and  
e.  the  process  for  abandoning  spinal  anaesthesia  in  favour  of  general  anaesthesia 

including clarity as to the decision makers; and  

4.  an indicative timeline in consideration of the DDI of 30 minutes, per the NICE guideline.  

We provide the policies/procedures and guidelines which inform this process map to evidence the 
clearly defined structures and systems in place at the Trust.  

Please see Appendix 2 – Process Map – Category 1 Caesarean Section / Fetal Bradycardia  

Communication and Culture 

As  an  organisation,  the  Trust  made  the  same  observations  as  the  Coroner  as  to  the  concerns 
regarding  communication  breakdown  as  between  the  obstetric  and  anaesthetic  teams  in  theatre, 
which the Trust considers to be at the heart of the difficulties encountered in theatre. Ahead of this 
Inquest, we acknowledged that these difficulties had led to avoidable delay.  

As part of an organic development in health practice but also designed specifically to address the 
issues  which  occurred  in  this  present  case,  particularly  focussed  on  culture,  leadership,  team 
working and compliance with national standards, the Trust undertook the following: 

1.  As  explained  in  evidence  to  the  Inquest,  the  Trust  has  radically  developed  its  training 
programme to an MDT model (between anaesthetists, obstetricians and midwives) which has 
been fully embedded, strengthened and follows a globally accepted, evidence-based human 
factors approach, known by the acronym PROMPT (Practical Obstetric Multi Professional 
Training) www.promptmaternity.org, which has been in effect at the Trust since January 
2021. 

2.  The  Trust  is  fully  compliant  with  the  Maternity  Incentive  Scheme,  as  operated  by  NHS 
Resolution on behalf of the Department of Health and Social Care. As part of this assurance 
programme, the Trust has had to evidence the implementation of a set of core safety actions, 
ultimately aiming to improve the quality of care for women, families and newborns. There are 
ten standardised safety actions in the scheme which have been agreed by senior (external) 
clinicians to help drive improvements in maternity, with a significant element of the actions 
targeting safety and culture. (Maternity Incentive Scheme - NHS Resolution) 

3.  As explained in evidence to the Inquest, the Trust has embedded SIMS training – real life 
Simulation Based Training which is based on obstetric emergencies and scenarios.  This is 
a learning tool used to improve team working in emergency procedures. The SIMS training 
includes learning from scenarios, incidents, case reviews, patients’ experience and themes 
and trends across the service to improve learning and reflection.  This facilitates constructive 
feedback to aid teams working together, learning from scenarios and dynamic integration into 
current themes on the maternity unit.   

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University of Leeds School of Medicine 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 9 

4.  GMC Professional Behaviours and Patient Safety Programme – the Trust entered into 
an agreement with the GMC to pilot a scheme designed to help organisations develop culture 
change and address unprofessional behaviours in clinical practice and to engender just and 
fair culture. 

5.  Perinatal  Culture  Leadership  programme  –  the  Trust  attended  the  Perinatal  Culture 
Leadership Training programme in 2024. The Perinatal Quadrumvirate consists of Midwifery, 
Obstetrics,  Neonates  and  Operational  Management.    The  programme  has  consisted  of 
understanding behaviours and cultures.  360-degree feedback and coaching was included 
within  the  programme.    A  SCORE  Survey  was  completed  in  April  2024  and  the  report 
received in the Trust in October 2024. Teams are currently drilling down into the feedback 
and producing an action plan.  Updates are presented to Quality and Safety Committee, Trust 
Board and Safety Champions.  

6.  As explained in evidence to the Inquest, the Trust has developed a programme of Human 
Factor  and  Ergonomics  Training  Workshops,  led  by  a  Consultant  Anaesthetist,  which 
focuses on systems issues within healthcare and how human behaviours influence outcome 
and  can  be  modified  through  systems  changes  to  achieve  better  clinical  outcomes  (the 
principles  of  such  training  are  explained  at  Human  factors  |  NHS  England  |  Workforce, 
training and education). 

7.  Compassionate  and  Inclusive  Leadership  with  Accountability  -  leaders  across  the 

organisation participated in this multiprofessional programme led by HealthSkills. 

8.  The external review of maternity services - the purpose of which was to provide external 
review of the service in order to provide external assurance and opinion, identify areas of 
good practice and provide any recommendations for improvement. The methodology firstly 
included  a  tabletop  review  of  Trust  self-assessment  against  CQC’s  key  lines  of  enquiry 
(‘KLOE’),  minutes  from  governance  meetings,  TOR,  completed  RCA’s  and  consultant  job 
plans.  This was then followed up by a two-day on-site visit which included discussions with 
members  of 
findings  and 
recommendations,  which  are  subject  to  a  specific  project  of  implementation,  many 
recommendations having already been implemented.  

followed  by  a  report 

incorporating 

It  was 

team. 

the 

9.  The  Trust  was  an  early  adopter  of  transitioning  to  Learn  from  Patient  Safety  Events 
(‘LFPSE’)  and  the  Patient  Safety  Incident  Response  Framework  (‘PSIRF’)  to  improve 
learning  and  safety  culture,  moving  away  from  root  cause  analysis  which  is  much  less 
effective in complex health systems. 

10. As  provided  in  evidence  to  the  Inquest,  the  Maternity  Department  has  introduced  (issued 
May 2023) a guideline ‘Maternity Escalation of Clinical Concerns Maternity Services’, 
which is designed to empower all staff members to raise clinical concerns and have agreed 
escalation processes in place. It incorporates the escalation toolkit provided by RCOG (2022) 
as part of their ‘Each Baby Counts: Learn + Support’ guidance (Each Baby Counts: Learn & 
Support | RCOG) 

11. As  explained  in  evidence  to  the  Inquest,  clinical  incident  reporting  is  an  embedded 
mechanism highlighting themes of clinical adverse events, in real time.  The Division have 
weekly  meetings  to  discuss  any  AEF’s  completed.  This  assists  with  early  identification  of 
themes, quality and safety and performance concerns and triggers for any immediate action 
and learning.  This AEF reporting process has the wider Trust oversight.  

12. As  explained  in  evidence  to  the  Inquest,  Quality  Safety  Summits  have  been  introduced 
across all disciplines in the Trust.  This has assisted with wider learning across all disciplines 
particularly when cases have required input from other specialities.  This has assisted as a 
mechanism  to  improve  wider  leaning  and  ongoing  quality  and  safety  improvements.   
Maternity contributes to this process given the complexities of women accessing the services 
and the requirements for multi-disciplinary engagement. 

In  summary,  the  organisation  aims  to  meet  the  challenges  around  workplace  culture  and  MDT 
collaboration head on and has undertaken an extensive programme of work to address and validate 
this area and will continue to do so. 

Associated Teaching Hospital of the 
University of Leeds School of Medicine 

 
 
 
 
 
 
 
 10 

As you will appreciate, this is an ongoing challenge for all NHS organisations and we have positioned 
ourselves to take on that challenge and benchmark the Trust against other organisations by working 
in  partnership  with  other  healthcare  providers,  and  to  engage  with  our  regulators  to  ensure 
compliance and best practice.   

I hope that this response addresses the concerns which you have raised and explains why the Trust 
has chosen to take the steps it has. I thank you for bringing these issues to our attention which we 
take very seriously. 

Yours sincerely 

Chief Executive 
Airedale NHS Foundation Trust 

Associated Teaching Hospital of the 
University of Leeds School of Medicine