Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0203, written 25 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Apr 2025 |
|---|---|
| Reference | 2025-0203 |
| Deceased | Jannat Abbker |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Jannat ABBKER (died 19.08.24)
THIS REPORT IS BEING SENT TO:
1. The President
Royal College Obstetricians and Gynaecologists (RCOG)
10-18 Union Street
London SE1 1SZ
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 23 August 2024, one of my assistant coroners, Edwin Buckett,
commenced an investigation into the death of Jannat Abbker, a baby
who died shortly after birth. The investigation concluded at the end of the
inquest yesterday. I made a determination at inquest that Jannat died as
a consequence of trauma suffered during birth as a result of shoulder
dystocia.
4
CIRCUMSTANCES OF THE DEATH
Jannat was a big baby and her mother had a history of shoulder dystocia
with two out of her three previous pregnancies. Her mum received
midwifery and obstetric care for the two pregnancies at University
College London Hospital (UCLH), and Jannat was delivered there.
1
Unfortunately, the fact of the shoulder dystocia was not communicated
to Jannat’s parents after the earlier births, and was not recognised by the
staff at UCLH during this pregnancy. If it had been, Jannat’s mother
would have been offered a Caesarean section for Jannat’s delivery. A
Caesarean section would have avoided the shoulder dystocia that
caused Jannat’s death.
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
With the benefit of a maternity and newborn safety investigation (MNSI),
UCLH is undertaking a significant piece of work to improve its systems.
However, there remains one outstanding point. When all else had failed,
Jannat was finally delivered by use of a manoeuvre called a shoulder
shrug. I heard at inquest that this is not a manoeuvre included within the
NICE (National Institute for Health and Care Excellence) guidelines, but
it is used abroad. One of the obstetric registrars looking after Jannat’s
mother had seen it in a training video.
I wonder if there is merit in considering this for inclusion in the next set
of relevant NICE guidelines, whenever these are updated?
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 23 June 2025. I, the coroner, may extend the
period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise, you must explain
why no action is proposed.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
• Jannat’s parents
• HHJ Alexia Durran, the Chief Coroner of England & Wales
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. She may send a copy of this report to any person who
she believes may find it useful or of interest. You may make
representations to me, the coroner, at the time of your response, about
the release or the publication of your response.
9
DATE SIGNED BY SENIOR CORONER
25.04.25 ME Hassell
3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
ME Hassell His Majesty’s Coroner for St Pancras Coroners Court Inner North London St Pancras Coroners Court Camley Street London N1C 4PP 19 June 2025 Dear Ms Hassell Re: Baby Jannat Abbker Your ref: Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Jannat Abbker on 25 April 2025. The loss of a baby is a devastating tragedy for parents, the wider family, and healthcare professionals involved. We would like to begin by extending our deepest and heartfelt condolences to Jannat’s family for their profound loss. This response has been developed following input from members of the Royal College of Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the College. We recognise and respect the narrative conclusion from the inquest that Jannat died as a consequence of trauma suffered during birth as a result of shoulder dystocia. We also recognise the matters of concern as outlined in your letter as follows, Jannat was finally delivered by use of a manoeuvre called a shoulder shrug. I heard at inquest that this is not a manoeuvre included within the NICE (National Institute for Health and Care Excellence) guidelines, but it is used abroad. One of the obstetric registrars looking after Jannat’s mother had seen it in a training video. I wonder if there is merit in considering this for inclusion in the next set of relevant NICE guidelines, whenever these are updated? The RCOG supports doctors to deliver maternity services through its educational initiatives. This encompasses developing curricula, elevating care standards through clinical guidance, assisting in career advancement through examinations, coordinating professional development initiatives and events, and offering support services to its members. Page 1 of 2 The RCOG Green Top Guideline (No. 42) on Shoulder Dystocia is due to be updated and published this year. This update has been in production for the last two years and is undergoing extensive development including comprehensive literature searches, internal and external review, involvement of key stakeholders and liaison with multi-professional specialists and experts. There is no NICE guidance on this topic and national guidelines are produced either by the RCOG or NICE to avoid replication. Relevant to the index birth, the guideline makes recommendations about mode of birth after a previous history of shoulder dystocia and delivery by planned caesarean birth is one of the recommended options, as referenced in your report. Intrapartum stillbirth is extremely rare at shoulder dystocia and current training programmes and the correct use of the release manoeuvres are as per the algorithm in the RCOG guidance. Reviewing the evidence, there are more than 100,000 vaginal births reported in the literature by training teams in the UK, United States, Spain and Germany with no permanent brachial plexus injury post shoulder dystocia (usual rate 3 per 10,000 vaginal births) and no intrapartum stillbirths. All these multi-professional teams used the clinical algorithm laid out in the RCOG Green-Top Guideline. There are other manoeuvres outside of those listed in the RCOG guidance as reported in the literature, for consideration, when the routine release manoeuvres have been unsuccessful. However, the data and evidence supporting these manoeuvres are extremely limited. The updated Shoulder dystocia guideline will include a section on ‘alternative manoeuvres’ based on good quality interventional research before making any new recommendations. We can confirm that the evidence for shoulder shrug has been considered, but the lead developers do not feel that there is sufficient evidence to currently recommend it in our evidence based RCOG management algorithm. However, effective training to manage shoulder dystocia using the mentioned release manoeuvres continues to be recommended and is also incentivised through the NHS Resolution Maternity Incentivisation Scheme to reduce morbidity and mortality to a minimum. Thank you for bringing this to our attention. I hope this is a helpful response to this matter. Yours sincerely, CEO Royal College of Obstetricians and Gynaecologists Page 2 of 2
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