Laura-Jane Seaman

H.M Area Coroner 
Ms Sonia Hayes 
SEAX House 
Victoria Road South 
Chelmsford 
Essex 
CM1 1QH 

Dear Ms Hayes 

Our Ref: 

7 February 2025 

Regulation 28 Report to Prevent Future Deaths- Laura-Jane Seaman 

I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 13th 
December 2024, relating to the Inquest of Ms Laura-Jane Seaman 

We have considered your concerns and set out our formal response to each matter using 
your numbering as follows. 

Matters of Concern 

(1) The acute Trust 72-hour investigation did not identify: 

a. The absence of a contemporaneous Labour Ward medication chart for a patient 
that was administered medications on the ward. 

All Mid and South Essex Hospital NHS Foundation Trust (‘MSE’) sites have now adopted 
an  electronic  prescribing  and  medication  administration  (EPMA)  platform.  EPMA 
facilitates team members across specialties to record accurately and contemporaneously 
in one place. The system allows all registered users to clearly see what other medications 
have been administered and by whom. Staff details are visible against the record so that 
each  interaction  is  name  and  date  stamped  within  the  patient  record.  This  aides  staff 
communication as it is clear who has been involved in the prescription of medications, 
and any queries or escalations can be quickly actioned. A new ‘e-chart’ is automatically 
started when there is a new  patient admission which limits the risk of drug errors and 
allows for re-evaluation of a patient’s medication.  

EPMA is used for the prescription of all medications with the exception of  variable rate 
infusions. These remain on paper charts at this time as the platform does not support 
medicines such as Insulin, magnesium sulphate and oxytocin infusion for augmentation. 
These are managed under specific variable infusion regimes in response to the patient’s 
clinical condition.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 b.  Significant  omissions  in  the  medical  record-keeping  and  some  medications 
administered were entered into a medication chart from a previous  admission in 
November 2023 

report 

(Rapid  Review) 

Our  72-hour 
response  was  completed  with 
Multidisciplinary (MDT) input in the immediate days following Laura-Jane’s death. Within 
the scope of the Rapid Review and MDT, the aim was to identify the immediate  urgent 
concerns  and  contributing  factors  that  led  to  this  tragic  outcome.  These  actions  were 
identified,  agreed,  and  put  in  place  to  make  immediate  improvements  and  prevent 
reoccurrence.  

learning 

The reviewing MDT panel agreed that a much more in-depth investigation was required 
to fully understand the situation and to draw out any additional concerns and learning. 
The  case  was  referred  to  Healthcare  Safety  Investigation  Branch  (HSIB)  as  maternal 
death meets the criteria for a referral to them. HSIB accepted the referral and undertook 
the  investigation.  Terms  of  reference  for  this  wider  investigation  are  mutually  agreed 
between  HSIB  and  the  Trust.  (HSIB  is  now  known  as  Maternity  and  Newborn  Safety 
Investigations (MNSI).  

The division acknowledges that the use of multiple medication charts was not included 
as a specific line of inquiry at the Rapid Review stage, and it should have been. We have 
reflected on the MDT meeting undertaken for Laura-Jane’s incident and we have made 
improvements to our processes. We now ensure that patient notes are uploaded as a 
digital copy in readiness for all MDT meetings so that whether meetings take place in 
person,  online  or  hybrid,  all  staff  attending  have  access  to  review  and  scrutinise  the 
patient’s notes. Therefore, minimising the risk that important factors such as  accuracy 
and quality record keeping are missed.  

c.  Vital  signs  for  patients  on  the  Labour  ward  being  annotated  on  a  piece  of 
cardiotocograph paper and the absence of required MEWS charts. 

Our  Rapid  Review  identified  this  issue,  and  several  immediate  actions  were  taken 
including urgent training delivered to staff to increase awareness and improve knowledge 
of MEWS charts.  

These actions included the immediate elimination of photocopied versions to ensure the 
coloured scoring was working as intended and prompting the expected trigger response 
in the escalation pathway.  

Please see section (2) below for an expanded narrative on how we have improved our 
use of MEWS charts. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 d. Communication issues with Trust staff and sharing of information. 

the  SBAR 

The  obstetric,  midwifery  and  anaesthetic  teams  have  yearly  Practical  Obstetric  Multi 
Professional  Training  (PROMPT)  training  sessions  as  an  MDT  where  they  role  play 
emergency scenarios. Since Laura-Jane’s death, during PROMPT, the team are taught 
about 
tool,  (Situation,  Background,  Assessment,  Recommendation). 
Escalation via the use of the SBAR tool is practiced teaching the quality and effectiveness 
of  good  communication.  SBAR  is  an  easy  to  remember  mechanism  to  use  to  frame 
communications or conversations. It is a structured way of communicating information 
that requires a response from the receiver. As such, SBAR can be used very effectively 
to escalate a clinical problem that requires immediate attention, or to facilitate efficient 
handover of patients between clinicians or clinical teams. 

In May 2023, the maternity education team facilitated an SBAR awareness week which 
focused  on  using  the  SBAR  tool  in  a  variety  of  scenarios  to  demonstrate  effective 
communication.  It  is  planned  to  revisit  this  topic  as  part  of  the  ‘awareness  week’ 
programme this year. 

As part of the Each Baby Counts initiative, the maternity service is launching the Royal 
College  of  Obstetricians  and  Gynaecologists’  (RCOG)  ‘Escalation  Toolkit’  in  February 
2025.  This  toolkit  is  designed  to  enhance  escalation  and  improve  patient  safety  and 
consists of three key components: 

1.  The AID (Advice Inform Do) mnemonic: A structured approach to frame escalation, 

followed by the use of SBAR. 

2.  The Teach or Treat Strategy: Encourages open discussions when there is a conflict 

in clinical opinion, ensuring a collaborative approach to decision-making. 

3.  Team  of  the  Shift  at  handovers  /  huddle:  Simplifies  the  escalation  process  and 

fosters a culture of psychological safety within the team. 

The toolkit aims to help staff get the response they need by using safety-critical language 
to initiate and frame the conversation. This is followed by the usual SBAR process. 

Effective  clinical  escalation  is  vital  for  patient  safety,  requiring  clear  and  concise 
communication with the right person at the right time. The goal is to clearly signal that 
escalation is happening, prompt a timely response, assist senior staff with prioritisation, 
and empower junior staff in their decision-making. 

When escalating, staff will be trained to use the safety-critical language from the RCOG 
framework. This language forms the AID tool and should headline SBAR communication. 

• 
• 
• 

"I am asking for ADVICE." 
"I am INFORMING you." 
"I need you to (DO). 

3 

 
 
 
 
 
 
 
 
 
 We will continue with this work and monitor compliance with the expected standards by 
audit. 

e. Lack of compliance with national guidance and training 

Trust  guidelines  are  reviewed  every  three  years  and  benchmarked  against  national 
guidance.  

The maternity specific training programme is reviewed annually, and obstetric emergency 
training uses / follows the PROMPT Maternity Foundation resources. In addition, it uses 
local incidents for learning and follows the CCFV2 (Core Competency Framework version 
2)  as  well  as  meeting  the  targets  for  SBLCB  (Saving  Babies  Lives  Care  Bundle)  and 
CNST action 8. 

Training compliance 01/11/21 until 31/10/22 for obstetric emergencies was at 85% for 
Midwives. Since this incident, compliance with all mandatory training for Midwives has 
remained 90-95%. 

f. Absence of contemporaneous blood testing results for Laura-Jane as a patient 
at high risk of post-partum haemorrhage in labour taken at: 

i. 00:40 hours for cross matching, and 
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient. 

Our Rapid Review included the documentation and results that were available for Laura-
Jane  at  the  time.  The  team  recognise  that  it  was  not  identified  at  the  time  that  some 
results were missing. As part of an initial review of an incident, all blood results are now 
considered as part of the MDT process. 

Since  August  2024,  the  maternity  unit  at  Broomfield  hospital  has  begun  the 
implementation  of  a  new  obstetric  bleeding  strategy.  The  strategy  works  alongside 
current PROMPT recommendations of managing a postpartum haemorrhage already in 
place at the maternity unit.  

The strategy is part of the Obstetric Bleeding Study UK (OBS UK) study and follows on 
from the Welsh study (OBS Cymru) where compliant hospitals have shown an increased 
compliance with the completion of bleeding risk assessments and quantitative blood loss 
measurements;  a  decrease  in  the  need  for  red  blood  cell  and  fresh  frozen  plasma 
transfusions and decreased Major Obstetric Haemorrhages (MOH). 

The strategy includes a four-part care bundle:  

1.  Risk assessing every birthing person's bleeding risk and continually reassessing       

throughout,  

2.  Real-time measurement of blood loss from the point of delivery,  

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  Consistent  approach  to  managing  excess  bleeding  and  involving  more  senior 

clinicians at specified timescales,  

4.  Bedside tests to rapidly identify and treat abnormal clotting.  

Every patient is given an OBS UK proforma at the point of admission (induction, labour, 
elective caesarean) and a risk assessment is completed. If the patient was to sustain a 
postpartum  haemorrhage  the  clinicians  would  progress  through  the  stages  of  the 
proforma and follow the prompts.  

At the point of 1litre blood loss with ongoing bleeding the patient will be offered a blood 
test  for  a  venous  blood  gas,  Thromboelastogram  (TEG),  FBC,  G&S  (if  not  already 
complete and in date) and coagulation sample +/- U&Es & LFTS depending on clinical 
situation. These samples can be repeated every 500mls after 1 litre to guide the clinicians 
as to what blood products are required.  

The  TEG  and  VBG  are  rapid  tests  which  will  have  results  available  usually  within  10 
minutes with the laboratory sample used as confirmation due to not being as rapid. The 
result is discussed with the team and the algorithm followed to administer blood products 
if required.  

An additional benefit to the study is the introduction of Fibrinogen concentrate to rapidly 
infuse  a  patient  to  clot  the  blood  and  reduce  further  loss.  This  is  an  alternative  to 
cryoprecipitate which takes additional time to thaw and be transported to maternity from 
the laboratory but can also be used within the study if required. Once the patient is stable 
the Post Partum Haemorrhage (PPH) post event checklist is completed to provide a plan 
of care for the patient postnatally.  

Due to the large scale of the strategy, the time taken to implement it has been inbuilt into 
the study and the first nine months from 1 August 2024 till 30 April 2025 is to be used as 
an implementation phase. This phase is provided to allow sites time to train and adopt 
the study without expecting 100% compliance straight away.  

To date, we have 91% training compliance of our target group of clinicians which is being 
reassessed after a new rotation of staff to ensure we remain above 90%. To assess our 
compliance of the strategy audits (first 30 consecutive births) and case note reviews (first 
ten consecutive births with 1litre loss or more) are undertaken at month one, four, seven 
and ten after the start of the study. Due to training of staff and development of a standard 
operating  procedure  (attached)  taking  a  number  of  months  the  strategy  did  not 
commence till 21st November 2024 with the last few months taken to drive the uptake of 
the  bundle.  To  reflect this,  the  service  undertook  an  additional audit  in  January which 
showed a 75% compliance across the board for risk assessments, measured blood loss 
and appropriate TEG testing. The service leads are continually reassessing with the local 
MDT and national teams for ways to improve the adoption of the strategy. 

5 

 
 
 
 
 
 
 
 
 
 
  
 
 In addition to implementing and auditing the strategy compliance, the research team have 
been monitoring all postpartum haemorrhage cases for birthing people who lose over 1.5 
litres and/or require a transfusion due to PPH since 1st February 2024. This includes, but 
is  not  limited  to;  blood  results,  length  of  hospital  stays,  maternal  and  neonatal  death, 
blood products given, contributions to PPH and actions taken. This data is fed back to 
the national study team and discussed with the local risk governance team during our 
obstetric haemorrhage reviews to collaborate on learning we can disseminate to staff.  

g. Lack of compliance with the triggering of the major haemorrhage protocol 

Although this concern was not specifically drawn out in the initial Rapid Review, the HSIB 
report  highlighted  this  as  a  safety  action  which  has  now  been  addressed  through 
education, training, and the amendment of local guidance. 

Following training and teaching there has been a significant increase in the utilisation of 
the MOH call. Latest figures (December 2024) demonstrated 83% compliance. This is 
monitored every month, and any issues addressed. The majority of MOHs occur in the 
theatre situation – namely during Caesarean Section. There is therefore anaesthetic and 
obstetric presence to manage the clinical situation, however acknowledgement has been 
given that putting out MOH calls to lab staff which means a timelier response can occur 
if blood products are required. In the majority of cases blood products are not required.  

(2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance 
with  training  and  national  guidance  including  PROMPT  training,  or  the  Royal 
College of Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and 
Puerperium  (RCOG)Green-top  Guideline  No.56.  The  maternal  collapse  was 
categorised as a  “Faint” by Trust  staff  and  Laura-Jane was  treated  for  potential 
dehydration (with no apparent risk factors) and administered medication that had 
only a transient effect. 

The service identified these issues in the initial review of the incident. Since Laura-Jane’s 
death there has been an implementation of a new MEWS package with escalation policy. 
This includes the trigger response/medical emergency team once a score of 7 or above 
is reached.  

MEWS  is  a  documentation  tool  designed  to  allow  early  recognition  of  physical 
deterioration in childbearing women by monitoring their physiological observations and 
allow for escalation when concerns arise. Serious adverse events such as cardiac arrest 
are  frequently  preceded  by  changes  in  physiological  parameters  and  recognising  and 
escalating a deteriorating patient has been shown to have a positive impact on morbidity 
and  mortality.  The  aim  of  implementing  the  MEWS  package  was  to  improve  our 
documentation, management, and patient safety outcomes within our maternity services.  

Maternity  now  has  good  compliance  with  plotting  observations  on  a  MEWS  chart  and 
escalating appropriately – this compliance is closely audited and monitored.  

6 

 
 
 
 
 
 
 
 
 
 
 
 Our post-incident review actions are set out chronologically below.  

1)  In January 2023, the education team took bite size learning to the ward on MEWS, 
followed by posters, shared learning by emails, they additionally included  MEWS 
and escalation in all PROMPT sessions monthly. PROMPT training is delivered in 
protected  time  outside  of  clinical  duties.  The  bite  size  education  was  delivered 
Monday to Friday by the education team during ward rounds with cascade training 
delivered  by  the  ward  matrons  and  managers.  Regular  audits  occurred  and 
findings were shared, and actions taken where appropriate. There was increased 
availability  of  MEWS  charts,  verbal  information,  posters,  and  emails.  The  2023 
Maternity  training  programme  additionally  included  escalation,  SBAR  and 
communication. 

2)  In March 2023, the service signed up to an East of England national pilot towards 
the  implementation  of  the  MEWS  chart.  The  project  received  oversight  and 
contribution  from  our  Obstetrics  Consultant  Lead,  Consultant  Midwife,  Inpatient 
Matron and Clinical Skills Facilitator. 

3)  By June 2023, the education team completed further face to face bite size teaching 
following audit of the MEWS charts and additionally shared this learning by email. 
Teaching took place on escalation pathways, completion of observation charts and 
scoring during PROMPT sessions with ward support. 

4)  In August 2023, the pathways for escalation were clarified and the team shared 
learning  and  commenced  formal  referral  to  the  ‘Trigger  response  team’  with  a 
MEWS score of 7, with consideration of Trigger response if a MEWS score reached 
5. In addition, all documentation for inpatients was changed to reflect the same.  

5)  By  October  2023,  the  service  was  planning  to  change  to  National  MEWS  and 
training commenced in January 2024. National MEWS went live on wards on 18th 
March  2024.  All  forms  and  documents  were  adapted  with  the  new  escalation 
pathway, and further ward support was provided.  

6)  National  MEWS  have  a  standardised  escalation  policy  to  follow,  this  includes 
involvement locally of the trigger response team as well as clear actions to take 
based on the MEWS score. This is audited as part of the MEWS audit, and we are 
demonstrating  good  compliance.  Escalation  is  taught  in  mandatory  training  and 
several verbal and written memos have been distributed to staff. This audit remains 
ongoing and is being closely monitored within the service by the Head of Midwifery, 
audit team, Quality Improvement Manager, and Inpatient Matron.  

7 

 
 
 
 
 
 
 
 
 
 
 7)  An ‘unwell woman’ simulation based on antepartum and postpartum haemorrhage 
including  uterine  rupture,  abruption,  and  Vasa  Previa,  as  well  as  a  separate 
simulation  on  an  anaphylaxis  scenario  was  included  in  the  2023  PROMPT 
maternity  training  for  all  staff  in  addition  to  Human  factors  training,  teamwork, 
situational awareness, and escalation.  

8)  Maternal collapse was taught to all staff in the  annual PROMPT training of 2024 
as  deteriorating  patient  with  a  focus  on  recognising  signs  of  an  unwell  patient, 
considering  differential  diagnoses  and  escalating  appropriately.  Obstetric  and 
midwifery staff attend protected mandatory PROMPT training yearly. 

9)  Focus on PPH management was taught in PROMPT throughout 2024. The Trust 
uses the standard guides produced by PROMPT which cover signs of hypovolemia 
but  do  not  directly  address  covert  bleeding.  Amendments  were  made  to  this 
programme at Broomfield and all MSE sites following Laura-Jane’s death. This now 
includes  signs  of  covert  bleeding,  initiating  the  2222  MOH  call,  escalation  and 
recognising deterioration including the signs and treatment of hypovolemia. 

10) In 2023 and 2024, live drills were conducted on the wards regularly and feedback 
and  learning  were  shared  with  all  staff  following.  Live  drills  are  scenario  based 
simulated skills sessions that take place in clinical areas. Staff are not made aware  
in advance that they are attending a simulated drill to gain the reaction and action 
required  in  dealing  with  obstetric  emergencies.  In  August  2024,  the  service 
delivered  a  deterioration  awareness  week  where  different  themes  were  shared, 
and learning distributed to all staff. 

Planned  training  for  PROMPT  2025  includes  a  deteriorating  patient  with  differential 
diagnoses and escalation as a simulated drill and additionally teaching sessions on the 
RCOG  escalation  tool kit  and  live  ward drills  are  also  planned.  The  RCOG  escalation 
toolkit will go live on 24th February 2025.  

Since January 2023, six midwives have attended the Anglia Ruskin University ‘Care of 
the  Critically  Unwell  Woman’  workshop.  Three  midwives  attended  the  Maternity  HDU 
course at Kings College London in May 2024. 

Each year midwives will be given the opportunity to apply for places on these courses to 
build the number of staff with this specialist skill.  

(3) The administration of Metaraminol on the Labour Ward is rare for a mother who 
had  an  uneventful  delivery  and  did  not  prompt  a  critical  care  review  with  a 
background of deranged vital signs 

As  explained  in  point  (2)  above,  we  have  now  implemented  the  MEWS  package  with 
escalation  policy  which  includes  a  trigger  response/medical  emergency  team  once  a 

8 

 
 
 
 
 
 
 
 
 
 
 
 score  of  7  or  above  is  reached.  This  change  has  allowed  for  rapid  critical  care 
involvement in cases where it has been needed and improved the working relationship 
and communication between critical care and maternity services, with shared language 
and clearly defined expectations prescribed within the tool.  

The administration of Metaraminol is an appropriate treatment given to someone who is 
hypotensive.  It  is  not  necessarily  a  marker  of  how  unwell  a  patient  is  -  a  patient  may 
transiently become hypotensive for example following a regional anaesthetic technique 
(epidural for example) or rapid infusion of IV paracetamol. Its repeated use (because of 
transient  response  to  the  medication)  would  indicate  a  problem  that  needs  further 
investigation  and  definitive  treatment.  Therefore,  Metaraminol's  repeated  use  should 
trigger a review by a senior anaesthetic and/or intensive care doctor. 

Consequently, where Metaraminol is administered and there is only a transient response, 
further clinical assessment must be undertaken by an appropriately trained anaesthetic 
and/or intensive care doctor. In this case the medical team agree that a review by critical 
care should have taken place 

With  regard  to  assessment  by  a  suitably  trained  doctor,  this  is  found  in  the  GPAS 
(Guidelines for the provision of anaesthetic services) document from the Royal College 
of Anaesthetists (RCoA) and the Curriculum for CCT in anaesthetics from the RCoA.  

(4)  There  was  a  focus  by  midwifery  staff  on  per  vaginal  bleeding  and  the 
hypovolemia  was  not  recognised.  The  PROMPT  training  guidance  contains 
illustrations by way of photographs to assist with the assessment of blood loss 
that focuses on per vaginal bleeding. Covert bleeding is referred to in the context 
of hypovolemia in a separate place on one line. Covert bleeding is not referred to 
in the Trust Drills & Skills Booklet. 

PROMPT  stopped  producing  books  for  candidates  and  the  last  edition  was  printed  in 
2019.  The booklet  provided  to  staff  was a  summary of  the  current  algorithms that  are 
provided in the 2021 and 2022 online PROMPT packages.  

The  Trust  used  the  standard  guidance  produced  by  PROMPT  which  cover  signs  of 
hypovolemia but do not directly address covert bleeding. We recognise that bleeding may 
be covert, and we have adapted the mandatory training and skills and drills sessions to 
reflect this as explained above. Training has focused on recognising signs of concealed 
bleeding and what action to take if these symptoms are present.  

Training  has  been  delivered  in  multiple  ways  on  this  topic  including  yearly  mandatory 
sessions, verbal teaching, live drills on the ward, dissemination of written information and 
in sharing learning from incidents.  

informed  clinical  professionals  she 

(5)  Laura-Jane 
thought  she  was 
haemorrhaging and that she was going to die in a background picture of maternal 
collapse  and  prolonged  deranged  vital  signs.  This  did  not  trigger  Consultant 
obstetric review, 2222 alert or referral to the critical care outreach team. 

9 

 
 
 
 
 
 
 
 
 
 
 The service recognises the failure to recognise how seriously unwell Laura-Jane was and 
the  delay  in  calling  for  immediate  help.  Training  has  now  been  embedded  to  aid  this 
recognition as described in the narrative response above for points two and four. Staff 
have  now  been  extensively  trained  on  when  to  escalate  and  who  to  contact  and  this 
information is now readily available and easy to access.  

In Laura-Jane’s case, although MEWS charts were available for use, it was found that 
not all staff used these consistently or correctly to record maternal observations. This led 
to significant delays in Laura-Jane receiving the care she required. Broomfield maternity 
have now adopted a new maternal observation chart known as the national MEWS. This 
chart is now mandatory for use for all maternity inpatients. The national MEWS escalation 
policy also includes referral to the trigger response (critical care) team. The new MEWS 
charts also include an additional trigger if the patient has concerns, which increases the 
score and level of review or escalation required.  

In the event of a similar deterioration and concealed bleed in the future the Consultant 
under this guidance, and with the above actions in place, would be alerted for a much 
earlier attendance. 

(6)  The  Trust  Executive  Review  Group  (“ERG”)  Report  was  not  shared  with  the 
Trust Director of Midwifery or the Head of Midwifery at Broomfield Hospital who 
did not agree with the ERG conclusions that: 

‘The  absence  of  escalation  to  an  obstetric  consultant  was  discussed  and  noted 
that the team escalated to an anaesthetist, which is usual practice in an obstetric 
emergency  (putting  out  a  call  to  the  medical  emergency  team  would  not  be 
common practice).’ 

‘The possible reasons why the bleeding was not identified were discussed and it 
was  noted  that  in  maternity  cases  the  absence  of  vaginal  bleeding  and  with  no 
signs of uterine rupture it would be unlikely that the team would have considered 
bleeding  as  a  cause  of  deterioration.’  and  gave  evidence  that  this  is  not  in 
accordance with good clinical practice or national guidelines and training. 

Following the conclusion of the Inquest, a reflective learning exercise was completed by 
senior  colleagues  in  the  service  to  understand  the  extent  to  which  the  incident 
investigation was shared within the team. We identified that there were opportunities to 
improve how complex cases such as this one are shared with colleagues as versions are 
edited and finalised. 

We have a new leadership  model, and the Director of Midwifery now attends all MDT 
meetings to ensure senior oversight for all cases. We are confident that all cases have 
senior oversight from start to finish, and all final versions are being shared appropriately. 

Following the Inquest, we have adapted our process for incidents presented at  Patient 
Safety Incident Review Group (PSIRG). We now have a failsafe to share the post meeting 

10 

 
 
 
 
 
 
 
 
 
 
 
 version of the document, including the decision sheet to the Senior Leadership Team and 
Governance Lead for the Site or Service presenting, this is in addition to the document 
being available within the Datix Risk Management System. Therefore, the possibility that 
an incident report is not shared with the appropriate staff is remote. 

Significant improvements and training have taken place as described in sections 3,4 and 
5 above to make sure that staff are competent to recognise when escalation is required, 
and clarity about to whom they should escalate. 

[7 & 8 were not included in the PFDR, and the Coroner’s officer has confirmed this 
was a numbering error] 

(9) Staff skill mix for doctors on the Labour Ward for the night of 20/21 December 
was staffed with a junior obstetric registrar with a newly qualified colleague in his 
first week and a junior anaesthetist, all with limited experience of working on the 
Labour Ward. 

The  RCOG  considers  documentary  evidence  of  signed-off  competency  as  a  senior 
registrar. This is in relation to specific cases described in RCOG documents of ‘Roles 
and responsibilities of the consultant providing acute care in obstetrics and gynaecology.’  

We now have a new rota system in place where the required staffing establishment must 
include  a  junior  registrar  paired  with  a  senior  registrar.  The  junior  then  has  a  point  of 
escalation to ensure that any  MEWS score of four or above is escalated to the senior 
registrar and onto the Consultant.  

The  SHO  role  is  subject  to  a  supervision  period  to  ensure  that  they  are  competent  to 
manage the busy environment and understand their routes of escalation and support. If 
the  junior/senior  mix  is  not  achievable  due  to  staffing  issues  the  rota  coordinator  will 
provide the detail to the Consultant on call to assess the risk and make appropriate plans 
at handover.  

If the skill mix is not possible to achieve due to a longer-term issue for example due to 
sickness, the rota coordinator will provide the detail of the skill mix of the staff available 
to the clinical lead who will make the decisions on how to safely staff the rota and what 
mitigations will be in place.  

(10) Quality of communication and handovers between Trust staff key information 
was  omitted in  handovers  between staff at all  levels  including when  Laura-Jane 
was taken to theatre as a medical emergency. 

We have taken action to improve communication across our teams, we have included 
this within our response to point 1(d) above. 

11 

 
 
 
 
 
 
 
 
 
 
 
 
 
 (11)  Therapeutic  anticoagulation  was  administered  without  consultant  obstetric 
input, further medical review, or imaging where there had been hours of deranged 
vital signs that were inconsistent potential complications for pulmonary embolism. 

Staff  focused on the signs and symptoms of  hypovolemia (both overt and covert) and 
how to manage and treat. The new MEWS score has an escalation policy which requires 
the involvement of an obstetric consultant when the score reaches 5 and above. This can 
be escalated prior to this point if a response has not been achieved within an acceptable 
time for lower scoring trigger. 

In Laura-Jane’s case the MEWS score was not completed, and so no formal escalation 
policy was followed. Staff have since had extensive training on completing MEWS charts 
and following the MEWS escalation and this is audited demonstrating good compliance. 
The investigation found that Laura-Jane was given the wrong diagnosis, and this was in 
part due to failure to recognise signs of concealed bleeding.  

As  set  out  above,  there  has  been  further  training  and  education  in  identifying  the 
deteriorating  patient/woman  and  is  now  embedded  within  PROMPT,  induction  of  new 
staff and local training sessions. The MEWS scores are discussed, and concerns raised 
at the daily huddles and handovers.  

(12) No  accounts  were  taken from  Haematology,  or  the  blood lab team  involved 
with  this  massive  haemorrhage  by  the  Trust  or  the  HSIB  (who  investigated  this 
case) where massive amounts of blood products were prepared,  dispensed, and 
then administered where the timings and sharing of information were important to 
understand. 

The service acknowledges that Haematology was not involved in the initial Rapid Review, 
and they should have been.  

The service now has an improved working relationship with haematology, critical  care, 
and  anaesthetics  with  regular  attendance  from  these  specialties  where  indicated. The 
Risk and Governance team now have a dedicated ITU consultant involved in reviewing 
any complex maternal care.  

The haematology service was disappointed not to be involved in the HSIB investigation. 
The  draft  HSIB  report  was  not  shared  widely  enough  to  capture  a  response  from  the 
haematology staff involved in the event with the assumption that the haematology staff 
were actively involved in HSIB investigation and aware of the draft report. The Trust is 
unable to comment why HSIB did not involve Haematology in their investigation.  

We have now renewed and improved our processes regarding MNSI investigations. The 
revised processes ensures that all staff involved in the incident are shared the draft report 
to facilitate the opportunity to comment for factual accuracy and for these comments to 
be shared with MNSI.  

12 

 
 
 
 
 
 
 
 
 
 
 
 
 During the period of factual accuracy checking, a meeting is arranged by the Maternity 
Governance Team, where the Corporate Patient Safety team are invited to attend. This 
meeting  facilitates  an  MDT  review  of  the  draft  report  for  factual  accuracy,  builds  a 
mechanism  to  ensure  all  staff  groups  have  been  shared  the  report  and  to  collate 
comments for onward sharing to MNSI. It is recognised that if the process now in place 
was  instigated  when  the  draft  HSIB  report  for  Laura-Jane  was  shared  with  the  Trust, 
there would have been an opportunity to have detected the concerns from haematology.  

Our  teams  have  reflected  deeply  on  Laura-Jane’s  experience  as  evidenced  by  the 
extensive  changes  and  improvements  set  out  above.  We  hope  that  these  actions  will 
assure  the  Court  we  have  made  significant  changes  to  our  practice,  and  we  are 
committed to ongoing learning from this very tragic case. 

If I can assist further with these matters, please do not hesitate to contact me. 

Yours sincerely 

Chief Executive 
Mid and South Essex NHS Foundation Trust 

13

Sonya Hayes 
His Majesty’s Coroner Area of Essex 
Essex Coroners Service 
Seax House 
Victoria Road South, 
Chelmsford,  
CM1 1QH 

Dear Ms Hayes, 

Re: Laura Jane Kirsten Nicole Seaman- deceased 

6 February 2025 

Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of 
Laura-Jane Seaman dated 18 December 2024. 

This loss is a devastating tragedy for the immediate and the wider family, and healthcare professionals 
involved. We would like to begin by extending our deepest and heartfelt condolences to Laura-Jane’s 
family for their profound 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 Laura Jane died as a consequence 
of lack of timely recognition and appropriate escalation of her clinical deterioration by healthcare 
professionals. 

We also recognise the matters of concern as outlined in your letter as follows,  

(1) The acute Trust 72-hour investigation did not identify: 

a. The absence of a contemporaneous Labour Ward medication chart for a patient 
that was administered medications on the ward 
b. Significant omissions in the medical record-keeping and some medications 
administered were entered into a medication chart from a previous admission in 
November 2023 
c. Vital signs for patients on the labour ward being annotated on a piece of 
cardiotocograph paper and the absence of required MEOWS charts 
d. Communication issues with Trust staff and sharing of information 
e. Lack of compliance with national guidance and training 
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient 
at high risk of post-partum haemorrhage in labour taken at 

i. 00:40 hours for cross matching, and 
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient 

g. Lack of compliance with the triggering of the major haemorrhage protocol 

Page 1 of 5 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
   
   
 
 (2) Laura-Jane was not escalated for hours as a deteriorating patient in accordance with training and 
national guidance including PROMPT training, or the Royal College of 
Obstetricians and Gynaecologists Maternal Collapse in Pregnancy and Puerperium 
(RCOG) Green-top Guideline No.56. The maternal collapse was categorised as a “faint” by Trust staff and 
Laura-Jane was treated for potential dehydration (with no apparent risk factors) and administered 
medication that had only a transient effect. 

(3) The administration of Metaraminol on the labour ward is rare for a mother who had an uneventful 
delivery and did not prompt a critical care review with a background of deranged vital signs. 

(4) There was a focus by midwifery staff on per vaginal bleeding and the hypovolemia was not recognised. 
The PROMPT training guidance contains illustrations by way of photographs to assist with the assessment 
of blood loss that focuses on per vaginal bleeding. Covert bleeding is referred to in the context of 
hypovolemia in a separate place on one line. Covert bleeding is not referred to in the Trust Drills & Skills 
Booklet. 

(5) Laura-Jane informed clinical professionals she thought she was haemorrhaging and that she was going 
to die in a background picture of maternal collapse and prolonged deranged vital signs. This did not trigger 
Consultant obstetric review, 2222 alert or referral to the critical care outreach team. 

(6) The Trust Executive Review Group (“ERG”) Report was not shared with the Trust 
Director of Midwifery or the Head of Midwifery at Broomfield Hospital who did not agree with the ERG 
conclusions that: 

‘The absence of escalation to an obstetric consultant was discussed and noted 
that the team escalated to an anaesthetist, which is usual practice in an obstetric emergency 
(putting out a call to the medical emergency team would not be common practice).’ 

‘The possible reasons why the bleeding was not identified were discussed and it was noted that in 
maternity cases the absence of vaginal bleeding and with no signs of uterine rupture it would be 
unlikely that the team would have considered bleeding as a cause of deterioration.’  

and gave evidence that this is not in accordance with good clinical practice or national guidelines and 
training. 

(9) Staff skill mix for doctors on the Labour Ward for the night of 20/21 December was staffed with a junior 
obstetric registrar with a newly qualified colleague in his first week and a junior anaesthetist, all with 
limited experience of working on the Labour Ward. 

(10) Quality of communication and handovers between Trust staff key information was omitted in 
handovers between staff at all levels including when Laura-Jane was taken to theatre as a medical 
emergency. 

(11) Therapeutic anticoagulation was administered without consultant obstetric input, 
further medical review or imaging where there had been hours of deranged vital signs that were 
inconsistent potential complications for pulmonary embolism. 

Page 2 of 5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (12) No accounts were taken from Haematology, or the blood lab team involved with this massive 
haemorrhage by the Trust or the HSIB (who investigated this case) where massive amounts of blood 
products were prepared, dispensed and then administered where the timings and sharing of information 
were important to understand. 

The Royal College of Obstetricians and Gynaecologists (RCOG) plays a vital role in supporting health care 
professionals with appropriate clinical care provision through its various initiatives around clinical guidance 
and education and training.  

There are clear clinical evidence-based guidelines for the management of obstetric emergencies which 
involves, recognition, escalation and multidisciplinary team (MDT) management with a helicopter view of 
the situation.      

The core competency framework1 has been developed by the maternity transformation programme, in 
collaboration with other national maternity and neonatal organisations. This framework aims to promote 
consistencies in training and competency assessments. It also ensures that essential training addressing 
key areas of harm, is implemented as a standard requirement across all maternity and neonatal services, 
fostering safer and consistent care delivery.  

The framework contains a module (3) on Medical emergencies and multiprofessional training specifically 
for maternal collapse, escalation and resuscitation. It includes the use of maternal critical care observation 
charts, structured review proformas with deterioration and escalation thresholds. NHS Trusts have to 
demonstrate that the requirement for MDT training has been met to comply with Action 8 of the maternity 
incentive scheme2 overseen by NHS resolution. 

The RCOG’s clinical guidance in this context includes the following: 

1.  Prevention and Management of Postpartum Haemorrhage3 (PPH) (Green-top Guideline No. 52). It 
clearly states that: “Clinicians should be aware that the visual estimation of peripartum blood loss is 
inaccurate, and that clinical signs and symptoms should be included in the assessment of PPH.”   

The guideline outlines a full protocol for monitoring and investigation in major PPH (blood loss greater 
than 1000 ml) and ongoing haemorrhage or clinical shock. This includes that: “Relevant staff with an 
appropriate level of expertise should be alerted of PPH.”  And: “The management of PPH requires a 
multidisciplinary approach: the anaesthetist plays a crucial role in maintaining haemodynamic stability and, 
if necessary, in determining and administering the most appropriate method of anaesthesia.” 

The guideline also advises: “recording of parameters on a modified early obstetric warning score (MEOWS) 
chart (and) acting and escalating promptly when abnormal scores from a MEOWS chart are observed.”  The 
guideline also recommends that: “all staff involved in maternity care should receive training in the 
management of obstetric emergencies, including the management of PPH and that the training for PPH 
should be multiprofessional and include team rehearsals”.  

2.  Maternal Collapse in Pregnancy and the Puerperium4 (Green-top Guideline No. 56). Clearly states 
that: “An obstetric modified early warning score chart should be used for all women undergoing 

Page 3 of 5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 observation, to allow early recognition of the woman who is becoming critically ill.” And that: 
“Maternal collapse can result from a number of causes. A systematic approach should be taken to 
identify the cause.” It advises that the cause of the maternal collapse should be rapidly identified 
and treated to prevent potential progression to maternal cardio-respiratory arrest. Ongoing regular 
ABCDE assessment should be performed as the risk of progression to cardiac arrest remains until 
the cause of the collapse is treated. “Abdominal ultrasound by a skilled operator can assist in the 
diagnosis of concealed haemorrhage.” 

The NICE guideline [NG235] on Intrapartum care 20235 also states: “continuously assess blood loss 
and the woman's condition and identify the source of the bleeding.” 

3.  Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium6 (Green-
top Guideline No. 37a April 2015) states that: “Low molecular weight heparin (LMWH) should be 
avoided, discontinued or postponed in women at risk of bleeding after careful consideration of the 
balance of risks of bleeding and thrombosis.”  

Metaraminol causes mainly systemic vasoconstriction. The use of metaraminol to treat hypotension due to 
distributive shock caused by anaesthetic agents is well known in the operating theatre setting. However, 
guidance for its use outside of this environment in critically ill patients with shock in the intensive care unit 
(ICU) is limited7. None of the RCOG guidelines advocate the use of metaraminol in treatment of shock or 
PPH. 

4.  Improving patient handover8 (Good Practice Paper No. 12). States that it is important to optimise 
communication of critical information as an essential component of risk management and patient 
safety. It goes on to describe two structured tools to use for effective communication between 
teams to improve the efficiency of communication. The two structured tools described by the 
RCOG are SBAR (situation – background – assessment – recommendation) and SHARING (Staff, 
High risk, Awaiting theatre, Recovery ward, Inductions, NICU, Gynaecology). These act as an aide 
memoir to provide appropriate team updates during handovers. 

5.  Good Practice Paper on Roles and responsibilities of the consultant providing acute care in 

obstetrics and gynaecology9 states that one of the general situations in which the consultant must 
attend is any return to theatre for obstetrics or gynaecology. Some of the other obstetrics reasons 
for attendance are early warning score protocol or sepsis screening tool that suggests critical 
deterioration where HDU / ITU care is likely to become necessary or maternal collapse or where 
‘major obstetric haemorrhage’ call has been instigated. 

The College supports the training run by the PROMPT Foundation which is a multi-professional skills and 
drills training programme for maternity units helping midwives, obstetricians, anaesthetists and other 
maternity team members be safer and more effective.  This should be undertaken to instil the importance 
of clear leadership, communication within the wider team and the ability to lead and provide a helicopter 
view in such scenarios. 

The College’s commitment firmly lies in improving maternity safety. This encompasses elevating care 
standards through clinical guidance and multidisciplinary training. It is imperative that the Trust’s 

Page 4 of 5 

 
 
 
 
 
 
 
 
 
 
 
 
 guidelines are in line with the national guidelines. The College strongly advocates the importance of the 
Trust’s guidelines being aligned with national guidelines.  

I hope this is a helpful response in this matter.  

Yours sincerely, 

CEO, Royal College of Obstetricians and Gynaecologists 

References: 
1.  NHS England Core competency framework v2: Minimum standards and stretch targets NHSE 
2.  NHS Resolution Maternity incentive Scheme  
3.  Prevention and Management of Postpartum Haemorrhage (PPH) (Green-top Guideline No. 52 - 2016).  
4.  Maternal Collapse in Pregnancy and the Puerperium. (Green-top Guideline No. 56-2019). 
5.  NICE guideline [NG235] on Intrapartum care 2023 
6.  Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium (Green-top 

Guideline No. 37a -2015) 

7.  Gamper G et al. Vasopressors for hypotensive shock. Cochrane Database Syst Rev 2016; 15: CD003709). 
8.  Improving patient handover (Good Practice Paper No. 12 2010). 
9.  Roles and responsibilities of the consultant providing acute care in obstetrics and gynaecology (2021) 

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