Elton Deutekom

FAO the Senior Coroner, 
Professor Fiona Wilcox 
Inner West London Coroner’s Court 
33 Tachbrook Street 
SW1V 2JR 

By Email 

Executive Office 
Chelsea and Westminster 
Hospital 
369 Fulham Road 
London SW10 9NH 

T: 020 3315 8000 
W: www.chelwest.nhs.uk 

24 January 2025 

Dear Senior Coroner, Professor Wilcox, 

Inquest touching the death of Baby Elton Deutekom – Response to Prevention of Future Deaths 
Report issued 02 December 2024 

I am the Chief Executive Officer writing on behalf of the Chelsea and Westminster Hospital NHS Foundation 
Trust, in response to the Regulation 28 report issued by the court on 02 December 2024, in relation to the 
death of Master Elton Deutekom, on 12 January 2022. We thank the Senior Coroner for bringing these concerns 
to the Trust’s attention and aim to address these, with this response. 

Firstly, on behalf of the Trust, I offer my sincere condolences to Elton’s parents and family. We wish to reassure 
them that care and service delivery problems identified both after his death and during the inquest process 
have been reflected upon and learned from.    

The Trust has also had sight of NHS England’s PFD response when making this response. 

I address each of the evidentiary points raised and thereafter the Matters of Concern, below: 

•  The  Trust  accepts  and  has  continued  to  reflect  upon  the  factual  findings  in  relation  to  evidentiary 
points 1-3 which are broadly in line with the findings of the external Healthcare Safety Investigation 
Branch (“HSIB”) investigation that followed shortly after Elton’s death following direct referral from 
the  Trust.  The  Trust  sought  to  address  these  findings  immediately  following  receipt  of  their 
investigation report, and the changes implemented are set out further under the relevant Matters of 
Concern below.  

• 

In respect of evidentiary point 4, the neonatal consultant who obtains consent for the post mortem is 
expected to provide the discharge summary to the Pathologist and/or complete a post mortem request 
form, in addition to speaking to them to highlight any relevant clinical information. We recognised that 
in this instance, on reviewing the summary there was no mention of the abruption. The consultant 
responsible  is  not  able  to  confirm  that  the  information  relating  to  the  abruption  was  subsequently 
passed on to the pathologist.  The Trust apologises for this oversight and has taken this learning back 
to the Neonatal team to ensure all information identified at the time of the birth is provided as part of 
highlighting relevant clinical information. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 • 

In respect of evidentiary point 5, the Coroner notes, “Issues in relation to management of labour that 
may have contributed to the death and thus render the death as reportable to the coroner under the 
Notification of Deaths Regulations (the Regulations) were noted on 17th January 2022 on a Datix 
report, in statements gathered in January and February 2022 and at the Perinatal Mortality Review 
meeting in early March 2022. On 11th April 2022, HSIB advised Chelsea and Westminster to report 
the death to the coroner based on issues they identified in relation to management of Elton’s mother’s 
labour. Despite this the death went unreported until 17th June 2022.” 

The  Trust  confirms  that  immediately  following  on  from  this  death,  the  neonatologists  felt  able  to 
establish a Medical Cause of Death and did not consider this was a matter that ought to be referred 
to the Coroner. Despite this, a referral was repeatedly explored, re-assessed and considered with the 
input of the wider medical team and Medical Examiners throughout January 2022 and all considered 
this did not meet the requirements for referral. The matter was again re-considered during the multi-
disciplinary Perinatal Mortality Report Tool meeting in March 2022, and the conclusion was it did not 
meet criteria for referral. A timely referral to HSIB was made following Elton’s death as part of the 
Trust’s usual processes.  

The Trust has been advised by HSIB following the inquest, that the letter dated 11 April 2022 and 
disclosed during the inquest process, was incorrectly dated and was not sent to the Trust until  11 
June 2022. This letter advised the Trust to again consider whether a referral to the Coroner ought to 
be made.  

This advice was followed, and within a week, the neonatal team contacted the Coroner on 17 June 
2022 and again on 22 June 2022. The Court opined that this did not fall in their jurisdiction and the 
Neonatal  team  clarified  that  this  was  a  neonatal  death  rather  than  a  stillbirth.   A  pre-investigation 
hearing was arranged for 16 July 2022, whereby the Trust clinicians attended and re-confirmed this 
position. An inquest was then opened, and the Trust has engaged throughout. 

• 

• 

• 

In respect of point 6, the Regulation 28 report states, “Explanation from the hospital was sought as 
to why the death was not reported in line with Regulations and a letter was received from the Lead 
for Neonatal mortality. This provided no clear explanation to many of the questions raised and 
demonstrated a lack of understanding of the Regulations and the obligation they place upon doctors 
to report deaths to coroners, and that these legal obligations continue after the death may have been 
registered as natural.” 

This point was raised prior to the inquest and the Trust prepared a letter in response (enclosed with 
this letter for ease of reference). During the inquest the Trust prepared a further written response 
from the neonatal team to assist the court. The Trust has responded to all requests and every effort 
has been made to ensure that the reporting systems and criteria have been set out.  The Trust is 
seeking  clarity  on  this  point  for  the  future,  and  is  eager  to  adopt  any  relevant  guidance  in  the 
framework  for  the  governance  of  neonatal  mortality,  currently  being  developed  by  the  British 
Association of Perinatal Medicine. 

In respect of evidentiary point 7, the Trust denies that statements and handwritten documentation by 
nursing staff were not disclosed, but appreciates that there was difficulty in establishing this position 
during the inquest, for which we apologise. A detailed timeline under Matter of Concern 2 is set out 
in respect of this point.  

In respect of evidentiary point 8, this is addressed in detail under Matter of Concern 3. For clarity, 
paper records were written up into the electronic record from handwritten notes recorded during the 

Page 2 

 
 
 
 
 
 
 
 
 emergent situation in line with Trust policy. Assistance was given in the context of mentoring, as the 
midwife  was  in  the  first  year  of  her  preceptorship  programme.  The  paper  note  which  had  been 
captured during the emergent delivery, was discarded once it had been accurately transcribed into 
the  electronic  record.  The  Trust  denies  any  suggestion  that  this  was  a  “cover  up”  and  wishes  to 
reassure Elton’s family of the same. 

• 

In  respect  of  evidentiary  point  9,  this  is  also  addressed  under  Matter  of  Concern  2,  but  the  Trust 
accepts there was confusion during another inquest as to what disclosure had been made and when, 
in the context of a lengthy investigation with voluminous documentation. As soon as this was identified 
in the inquest, the Trust legal team took immediate steps to ensure the parties had all received the 
documentation and re-disclosed the records to address any disparities. There was no intention by the 
Organisation or its employees to prevent disclosure of full records at any time. The Trust feels that 
this had been adequately addressed in that inquest, and therefore this was not contextually relevant 
to Elton’s inquest. 

•  The Trust has addressed evidentiary points 10 and 11 under Matter of Concern 7. Medical Examiners 
for the Trust now have full access to maternal and baby notes when reviewing deaths and will review 
them, in accordance with appropriate consent. 

Matters of Concern 

In respect of the Matters of Concern to be addressed in the Regulation 28 Report, the Trust confirms: 

1.  That Chelsea and Westminster Hospital are not appropriately referring neonatal deaths 
to coroner- either late or not at all, and this raises the possibly that lessons may not be 
learned from the investigation of these deaths that may save the lives of others. 

The Trust is confident that it meets its obligations in respect of referring neonatal deaths to the Coroner. 

All deaths are now required to be reviewed under statutory duty of the Medical Examiner, therefore all neonatal 
deaths are reviewed. The Medical Examiners have confirmed that they have full access to maternal/obstetric 
notes as part of the review process and will access them when appropriate consent has been obtained with 
regard to maternal records. 

Please find enclosed the Trust’s “Medical Examiner Process flowchart”, which also sets out how the Medical 
Examiners assess each neonatal death.  

The Neonatal team liaise with the Medical Examiners and maternity teams in the event of a neonatal death 
and referrals are made appropriately and according to existing criteria.  

Furthermore, all neonatal deaths are reviewed by a large multi-disciplinary team including external attendees 
and the Child Death Overview Panel within 6 weeks, using the national Perinatal Mortality Review Tool. This 
is the standard process for learning from neonatal deaths that has been in place since 2018.  

It has been reiterated to staff in the service and to the wider leadership team of the Trust that any concerns 
held with regard to circumstances surrounding a death, should prompt a referral to the Coroner.  

2.  That Chelsea and Westminster Hospital may not be complying with the duty of candour 
to disclose evidence relevant to a death to the coroner until forced to by court directions 
made in public, which thus raises the same concern as above. 

The Trust takes seriously its obligations in respect of both Duty of Candour and disclosure, and endeavours to 
engage with and assist the court in all matters.  

Page 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 It is denied that the court was not provided with the evidence it required when requested. As set out below, 
the Trust has confirmed that disclosure was made at the times requested prior to inquest, on 16 May 2023. 
Emails confirming this fact are enclosed for the attention of the Coroner. Despite this, the Trust appreciates 
that there were difficulties in establishing what had been disclosed and when during the hearing, and has fed 
this back internally. 

The Trust understands that the documents in question were a statement from the Obstetric Registrar and a 
statement from the Labour Ward Co-Ordinator, as well as a paper handover note that was used during live 
evidence in the course of the inquest.  

The  Trust’s  external  and  internal  legal  team  have  each  reviewed  notes  of  previous  court  attendances  and 
confirm  that  in  a  Pre-Inquest  Review  Hearing  on  14  March  2023,  the  relevant  incident  statements  were 
discussed and it was requested they be disclosed to the Coroner to assess whether the family ought to see 
them.  

The  Trust  records  demonstrate  that  the  Trust  sent  documentation  to  its  external  solicitor  who  provided 
disclosure to the Court, on 16 May 2023.  

The Trust is reviewing its internal legal and governance processes to ensure clear records of disclosure are 
maintained so that we may provide assurance should the need arise in future.   

3.  That following neonatal deaths assistance is given to midwifery staff as to how to write 
records in retrospect and contemporaneous handwritten notes are destroyed possibly 
reducing the accuracy of the records and thus risking that lessons may not be learned 
that may save the lives of others. 

The  Trust has  clear policies in place  for record-keeping, and in respect of maternity and/or nursing notes, 
these remain in line with the NMC Code, Professional standards of Practice and Behaviour for Nurses, 
Midwives and Nursing Associates.  

The Trust reviewed the record-keeping as part of the response to the HSIB investigation and following receipt 
of this Regulation 28 report and confirms that: 

Notes were recorded in retrospect in this matter due to the emergent nature of the delivery.  This is a practice 
used throughout the NHS.  They were recorded in line with the Trust’s Maternity Clinical Record Keeping Policy 
and the relevant NMC Code, Professional Standards of Practice and Behaviour for Nurses, Midwives 
and Nursing Associates, October 2018 – Standards Relevant to Record Keeping, in place at the time 
of Elton’s death. 

The  Practice  Development  Midwife  acted  as  a  preceptor  for  the  junior  Midwife  involved  and  assisted  in 
demonstrating proper record keeping, as per Preceptorship policy and the NMC Principles for Preceptorship, 
which  is  the  expected  and  recommended  standard.  This  is  also  in  line  with  NHS  England’s  National 
Preceptorship Framework. 

Paragraph 1.4 of the NMC Principles for Preceptorship (point 3, page 10) states, “Preceptorship is tailored to 
the individual nurse, midwife and nursing associate preceptee’s new role and the health or care setting. It 
seeks to recognise and support the needs of the preceptee to promote their confidence in their professional 
healthcare role. In effective preceptorship models, preceptees: are provided with the appropriate resources to 
enable them to develop confidence as newly registered nurses, midwives and nursing associates  

•  Are supported according to their individual learning needs 

•  Are supported by a nominated preceptor 

•  Have  opportunities  for  reflection  and  feedback  to  support  their  approach  to  preparing  for 

revalidation…’ 

Page 4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.  That the labour ward is understaffed. 

The Trust has addressed the staffing gaps with an ongoing recruitment and retention programme. 

This  staffing  gap  was  accepted  by  the  Trust  at  the  time  of  the  HSIB  investigation  and  during  the  inquest 
process.  

Enclosed and set out below is the 2021 Birthrate Plus report (the Birthrate Plus staffing tool is the validated 
tool for the calculation of the maternity workforce and is based on activity, acuity and complexity data), which 
is part of requirements of the NHS Resolution Maternity Incentive Scheme.  The Trust has been compliant 
with this Scheme for the past 5 years and are on track to submit compliance in Year 6.  

This report demonstrates on page 15 that the gap in staffing on the Chelsea Hospital site in May 2021 was: 
10.95 whole time equivalent (WTE) midwives and 9.2 in specialist and management.   

Following  this  case,  the  Trust  received  21  WTE  from  the  national  funding  and  then  the  business  case  for 
investment was approved in December 2022, for funding over 4 phases as we recruited to the posts.   

The Maternity service will be fully recruited to Phase 3 by March 2025. Following this, the Trust Executive 
Management  Board  and  Finance  Investment  Committee  will  receive  a  business  case  for  phase  4  (on  the 
Chelsea Site the equates to 1 WTE clinical midwife and 1 WTE specialist and management), in addition to any 
proposed further investment following the Birth Rate Plus Review in April 2025. This will be to ensure we are 
at near-full capacity in terms of staffing.  This funding has meant that the Maternity Unit has been able to lift 
the staffing in areas to improve safety, having put in a night site safety coordinator on the Chelsea site. This 
was identified as learning within the Trust’s Action Plans. The Maternity team continue to use the NHSE funding 
for the preceptorship support midwife.  

The Maternity team have also proactively undertaken the “3 year birth rate plus assessment” and have just 
received the draft which will go to Executive Management Board (EMB) in February for review and ask for 
investment if required.  

The Trust has addressed the staffing gaps with its ongoing recruitment and retention programme. Given the 
national  position  regarding  midwifery  vacancies,  the  Trust  has  invested  in  the  workforce  and  worked 
collaboratively across North West London undertaking domestic and international recruitment, in addition to 
supporting the service in continuing to recruit to turnover any maternity leave posts. Shift fill rates within the 
maternity service are reviewed monthly and on the Chelsea Hospital site range from 98-100% of shifts filled 
to  the  expected  staffing  levels,  the  service  utilize  temporary  staffing  to  ensure  safe  staffing  levels.  All 
temporary staff complete an orientation and either complete local mandatory training or approved external 
training.  

Page 5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 5.  That newly qualified midwives should have more supervision whilst they are managing 

women in labour. 

Since Elton’s death,  new framework was published in March  2023 regarding supervision of newly qualified 
midwives whilst managing women in labour.  

The initial preceptorship programme began in January 2022 and was in line with national recommendations 
at that time.  

Please find enclosed the Capital Midwife Preceptorship Framework that was in place at the time of the incident. 
The framework stipulated that new starters should have “one week (or equivalent) of supernumerary time at 
the start of each rotation”; it did not specify what this meant in hours or whether this was pro rata for part-
time staff members.  

After completing a gap analysis and implementing any outstanding actions in March 2021, both hospital sites 
were awarded the CapitalMidwife Preceptorship quality mark, which was uniformly achieved across London by 
January 2023.  

The new midwifery preceptorship framework published by NHSE in March 2023 was implemented at the Trust 
by September 2023 and remains in place. This current framework stipulates that all preceptees should have 
supernumerary status for a minimum of 150 hours over a 12-month period, which usually means 75 hours at 
the  start  of  each  new  rotation/area.  The  programme  also  strengthens  the  provision  of  protected  time  for 
preceptee/preceptor progress meetings and any additional support required.  

The  Trust  has  investigated  the  levels  of  clinical  support  given  to  preceptee  midwives  and  confirms  that  in 
practice, a Practice Development Midwife is allocated for clinical support, though this has been affected by 
staffing as posts are presently not fully recruited to.  

In the context of clinical oversight during labour care, NHS Resolution’s Maternity Incentive Scheme outlines 
ten maternity safety actions, among which Safety Action 5 requires that the labour ward coordinator should 
remain supernumerary to ensure oversight of all birth-related activities and enhance patient safety. The Trust 
is fully compliant with this standard. 

6.  That there is no regular review system for CTGs on the central CTG monitoring board. 

This was accepted following on from the HSIB report and as a direct result of the recommendations, the Trust 
updated the current Intrapartum Fetal Monitoring Guideline to confirm that all CTG’s must be confirmed at a 
patient’s bedside. This is in line with the NICE Guidance and the Saving Babies Lives Care Bundle v3 that says 
a holistic review should take place hourly. The holistic review incorporates a categorisation of the CTG and 
requires  a  discussion  between  the  midwife  caring  for  the  woman/birthing  person  and  another  midwife  or 
doctor, which cannot be achieved at the central CTG monitoring screen, the outcome of this holistic review is 
discussed  with  the  woman/birthing  person.  The  CTG  central  monitoring  screen  can  be  a  useful  tool  in 
supporting MDT discussions and teaching of fetal wellbeing. The service has seen significant improvement in 
the compliance with the hourly holistic review and submitted compliance with this intervention as part of SBLv3 
which is part of the national Maternity Incentive Scheme.    

The Trust has provided further learning through a Fetal Monitoring Study day from 2023 onwards the service 
has maintained compliance with over 90% of staff having undertaken and passed a fetal wellbeing study day 
annually since the introduction of this study day alongside weekly drop in session to review cases. The case 
of Baby Elton was presented at each study day in 2024, including discussions around central monitoring.  The 
Trust has ensured further refreshers and training through six separate newsletters surrounding “Fresh Eyes 
CTG Reviews” since Baby Elton’s death, which has seen improved practice. This has been undertaken alongside 
a Fetal Monitoring Campaign through posters on the Maternity Units and through emails.  

Page 6 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 7.  That in some hospitals the Medical Examiners do not have access to obstetric records 

when reviewing deaths. 

At the time of Elton’s death, maternal/obstetric notes were not readily available and were requested by the 
Medical Examiners; however they now have access, within standard information governance processes. The 
Trust  is  unaware  whether  there  is  a  wider  concern  but  confirms  that  in  respect  of  this  Trust,  no  concern 
remains. 

8.  That the neonatologists at Chelsea and Westminster are not passing sufficient and 
appropriate information to the pathologists when consented post-mortem examinations 
occur such that the cause of death found by the pathologist may be inaccurate. 

In  this  instance  on  reviewing  the  summary  there  was  not  a  mention  of  the  abruption.  The  consultant 
responsible  is  not  able  to  confirm  that  the  information  relating  to  the  abruption  was  passed  on  to  the 
pathologist. This appears to be an individual oversight and has been fed back to the clinician involved.  

The neonatal consultant who obtains consent for the post mortem provides the baby’s discharge summary to 
the Pathologist and / or completes a post mortem request form, in addition to speaking to them to highlight 
any relevant clinical information.  

May I once again extend my sincere condolences to Elton’s family. I trust that the information provided has 
delivered assurance that the concerns raised have been addressed. 

Yours sincerely 

Enclosures: 

1.  Letter from Trust regarding referral to Coroner 201124 
2.  Neonatal contact with the Coroner – June 2022 
3.  Initial letter regarding late death referral - 13 November 2024 
4.  Letter from Trust regarding referral to Coroner - 20 November 2024 
5.  ME Flowchart - 24 October 2024 
6.  Disclosure to court in May 2023 
7.  NMC Code 
8.  Clinical Record-Keeping Policy 
9.  Maternity Clinical Record-Keeping Policy 
10.  CW Birthrate Plus Report 2021 
11.  CapitalMidwife Preceptorship Framework 2019 
12.  Intrapartum Fetal Monitoring Guidelines October 2024 
13.  Fetal Monitoring Campaign 
14.  Fresh Eyes Newsletters 

Page 7

Professor Fiona J Wilcox 
HM Senior Coroner  
Inner West London Coroner’s Court 
33 Tachbrook Street 
London 
SW1V 2JR 

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

22 January 2025 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Elton Michael Deutekom 
who died on 12 January 2022  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  2 
December 2024 concerning the death of Elton Michael Deutekom on 12 January 2022. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Elton’s parents and family. NHS England are keen 
to assure the family and the Coroner that the concerns raised about Elton’s care have 
been listened to and reflected upon.   

My response to your Report focuses on the areas of concern raised by the Coroner 
that sit within NHS England’s national policy and programme remit. Your Report raises 
a  number  of  concerns  specific  to  Chelsea  and  Westminster  Hospital  and  it  is 
appropriate  that  Chelsea  and  Westminster  NHS  Foundation  Trust,  who  I  note  you 
have also sent your Report to, respond to you on these matters. I wish to assure you 
that the National Medical Examiner, who you have also addressed your Report to, has 
reviewed your Report and has input into my response.  

I respond to each of your concerns relevant to NHS England in turn below.  

That  newly  qualified  midwives  should  have  more  supervision  whilst  they  are 
managing women in labour (concern no.5) 

NHS  providers,  under  the  NHS  Standard  Contract,  are  required  to  ensure  that  all 
midwives  meet  the  necessary  qualifications,  competencies,  and  receive  adequate 
supervision, including preceptorship and oversight.  

For  newly  qualified  midwives,  it  is  for  NHS  providers  to  design  preceptorship 
programmes aligned with NHS England’s National Preceptorship Framework, tailored 
to  local  service  configurations.  These  programmes,  recommended  in  the  first  year 
post-registration, provide structured support, protected learning time, and access to 
experienced preceptors (teachers or instructors) to develop autonomous practice and 
ensure  safe,  high-quality  care.  During  preceptorship,  newly  qualified  midwives  are 
recommended to have supernumerary status for a minimum of four weeks (150 hours) 
across the year, typically allocated at the start of rotations or clinical placements. This 
means that they are not allocated personal caseloads or included in staffing numbers 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 during this period. Any additional training needs identified should prompt individualised 
support plans at the provider’s discretion.  

NHS providers should ensure that all midwives (including those post-preceptorship) 
have access to clinical supervision through the A-EQUIP (Advocating and Educating 
for  QUality  ImProvement)  model,  delivered  by  Professional  Midwifery  Advocates 
(PMAs). PMAs provide structured support and guidance, enhancing care quality and 
workforce  well-being.  NHS  England’s  A-EQUIP  operational  guidance  prompts 
providers  to  consider  how  and  what  type  of  support  will  be  put  in  place  to  enable 
midwives  to  seek  immediate  support,  engage  in  proactive  planning,  mitigate  risks, 
address  midwifery  learning  and  development  needs,  and  create  opportunities  to 
discuss  the  woman’s  birth  experience  and  choices.  Additionally,  in  the  context  of 
clinical  oversight  during  labour  care,  NHS  Resolution’s  Maternity  Incentive  Scheme 
outlines ten maternity safety actions, among which Safety Action 5 requires that the 
labour ward coordinator should remain supernumerary to ensure oversight of all birth-
related activities and enhance patient safety. 

That there is no regular review system for CTGs on the central CTG monitoring 
board (concern no.6) 

The Maternity and Neonatal Programme cannot comment on the local practice and 
guidance for reviewing CTGs in this case, but provider trusts are expected to deliver 
care in line with NICE guidance. In addition, the Saving Babies Lives Care Bundle v3 
does include guidance for fetal monitoring during labour, including an hourly holistic 
review of cardiotocograph (CTG) monitoring at the bedside with the woman.  

This  review  should  include  not  just  analysis  of  the  CTG,  but  also  consideration  of 
antenatal  risk  factors  such  as  concurrent  reduced  fetal  movements,  fetal  growth 
restriction  and  previous  caesarean  section;  and  intrapartum  risk  factors  such  as 
meconium, suspected infection, vaginal bleeding or prolonged labour, and should lead 
to escalation if indicated. 

While  central  monitoring  systems  can  be  a  useful  additional  tool,  when  there  are 
additional  staff  available  to  observe  them,  the  holistic  review  is  more  than  just  a 
categorisation of the CTG and requires a discussion between the midwife caring for 
the woman and another midwife or doctor.  

Trusts  should be  able to  demonstrate  that all  qualified  staff  who  care  for  women  in 
labour are competent to interpret CTGs in relation to the clinical situation and escalate 
accordingly when concerns arise, or risks develop. 

That in some hospitals the Medical Examiners do not have access to obstetric 
records when reviewing deaths (concern no.7) 

At  the  time  of  these  events,  NHS  trusts  were  implementing  the  medical  examiner 
system  on  a  non-statutory  basis  and  were  not  yet  reviewing  all  deaths.  The 
government decided in April 2024 that, from 9 September 2024, the Death Certification 
Reforms  would  come  into  force,  including  the  statutory  medical  examiner  system.  

  
 
 
 Since this date, it has been a requirement that all deaths in England and Wales are 
independently reviewed without exception, either by a medical examiner or a coroner.   

Part  of  medical  examiners’  role  is  to  consider  whether  referral  to  the  coroner  is 
required, and to ensure more consistent referral of appropriate cases where the cause 
of death cannot be established, or the Notification of Deaths Regulations 2019 apply 
for other reasons. For all other cases, upon receiving a Medical Certificate of Cause 
of  Death  (MCCD)  from  an  attending  practitioner,  medical  examiners  are  under  a 
statutory duty to scrutinise the cause of death; consider the information provided by 
the  attending  practitioner;  make  whatever  enquiries  they  consider  necessary;  and 
confirm the cause of death by signing off the MCCD.   

The Access to Health Records Act 1990 (AHRA) has been amended to establish the 
statutory right of medical examiners to access health records of deceased patients, to 
enable  them  to  make  whatever  enquiries  they  consider  necessary.  Attending 
practitioners  are  now  required  by  the  Medical  Certificate  of  Cause  of  Death 
Regulations 2024 to make the deceased person’s relevant health records available to 
the medical examiner. 

In  some  neonatal  cases,  medical  examiners  may  consider  the  maternal  patient 
records are relevant. Unless the mother is also deceased and her death is undergoing 
scrutiny by the same medical examiner, the specific medical examiner’s right of access 
to these records under the Access to Health Records Act 1990 would not apply. If this 
is not the case, the usual information governance principles for living patients would 
apply to access to the maternal patient records (for example, obtaining consent from 
the living patient or establishing another legal basis). 

That  neonatologists  in  other  hospitals  may  not  be  appropriately  reporting 
deaths to the coroner (concern no.9) 

The  new  national  medical  examiner  (ME)  system  was  introduced  on  9 September 
2024 and all Medical Certificates of Cause of Death (MCCDs), including for neonatal 
deaths not investigated by a coroner, are reviewed by a medical examiner to ensure 
that the MCCD is completed accurately, that concerns of family members are taken 
into account following the death of a baby, and that deaths are appropriately reported 
to the coroner when indicated. This process was not in place in 2022 when the death 
of Elton occurred. 

In  addition,  the  British  Association  of  Perinatal  Medicine  is  currently  developing  a 
framework  for  the  governance  of  neonatal mortality.  This  will  be  available  later  this 
year and will provide specific guidance on good practice following a neonatal death. 
The  working  group  includes  neonatologists,  neonatal  nurses,  pathologists,  medical 
examiners and a representative of the Chief Coroner's office. We would be happy to 
share the document with the Coroner once it is available. 

Regional Review  

My regional Clinical Quality & Patient Safety colleagues for the region of London have 
also  reviewed  your  Report  and  are  engaging  with  relevant  regional  and  system 
colleagues for the appropriate oversight.   

  
 
 refreshed 

London  has  a  strong  record  regarding  preceptorship.  In  summer  2022,  the  London 
CapitalMidwife  Programme 
its  2019  CapitalMidwife  Preceptorship 
Framework, collaborating with local, regional and national stakeholders across clinical 
practice,  education  and  leadership.  This  work  informed  the  development  of  the 
National Preceptorship Framework. By January 2023, all London maternity units had 
achieved  the  CapitalMidwife  Preceptorship  Framework  Quality  Mark  requiring  only 
minor adjustments to align with the national standard introduced later that year and 
referenced above.  

In  January  2024,  London’s  regional  Maternity  Team  also  established  a  six-weekly, 
multiagency and multidisciplinary Perinatal Quality, Safety, and Surveillance Group to 
improve  safety  and  service  user  experience  through  person-centred  care,  a  safety 
culture, and continuous learning. Outputs are escalated to regional and national quality 
and safety groups as required.   

I  would  also  like  to  provide  further  assurances  on  the  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 events, such as the sad death of Elton, 
are shared across the NHS at both a national and regional level and helps us to 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