Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0457, written 8 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Sep 2025 |
|---|---|
| Reference | 2025-0457 |
| Deceased | Mabel Williams |
| Coroner | Robert Sowersby |
| Coroner area | Avon |
| Category | Child Death (from 2015) |
| 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 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The President Royal College Obstetricians and Gynaecologists (RCOG) 10-18 Union Street London SE1 1SZ 1 CORONER I am Robert Sowersby, assistant coroner for the coroner area of Avon 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 19 October 2023 I commenced an investigation into the death of Mabel Olivia Williams, who died when she was 6 days old. The investigation concluded at the end of the inquest on 15 August 2025. The medical cause of Mabel’s death was 1a) Severe hypoxic ischaemic encephalopathy, 1b) Undiagnosed uterine rupture. had previously given birth vaginally and later by Mabel’s mother, caesarean section. During the period before Mabel’s birth was for vaginal birth, but she was particularly anxious about pregnancy and birth, fearful that she might lose Mabel, and keen to pursue the safest option she could for her unborn daughter. preference was warned antenatally that if she trialed vaginal birth after caesarean section (VBAC) she might experience “uterine rupture” or “uterine scar rupture”, but at no point was she told what that phrase actually meant, how severe rupture could be, or that it could carry with it the risk of death for her unborn child (or indeed for her). On 4 September 2023 Western Hospital in Swindon. During VBAC she was induced, and in due course she was started on synthetic oxytocin without being counselled that this further increased the risk of uterine rupture. chose to undergo a trial of VBAC at the Great A number of further significant errors were made in course she experienced progressive uterine rupture which caused increasing distress and ultimately a fatal hypoxic episode for Mabel, who was born alive but died 6 days later. care and in due My conclusion at the end of the inquest was that “Mabel died because numerous indicators of her own distress, and of the increasing severity of her mother’s clinical condition, went unrecognised by the midwifery staff involved in her care or were not conveyed to the clinical team in time to expedite her birth safely. Neglect contributed to Mabel’s tragic death.” I was also very concerned that appropriate steps had not been taken to ensure understood the nature of one of the most significant risks of VBAC. 4 CIRCUMSTANCES OF THE DEATH The background to Mabel’s fatal hypoxic injury is set out above. She sadly died 6 days later in the Neonatal Intensive Care Unit of a hospital in Bristol. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – was advised about VBAC she was referred to internal guidance When from the hospital and to the RCOG’s information leaflet “Birth options after previous caesarean section” (published in July 2016). I reviewed the information leaflet and it does not contain any indication that uterine rupture could potentially prove fatal for mother and / or baby. My concern is that prospective parents may rely on this information leaflet to assist them in making informed choices about their birth options, and that if the risk is not identified then other patients like might pursue VBAC in circumstances where – if they had understood the risk better – they would have chosen otherwise. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation 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 3 November 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons ( NHS Foundation Trust). , and the Great Western Hospitals 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. He may send a copy of this report to any person who he 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 8 September 2025
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.
Robert Sowersby
His Majesty’s Senior Coroner Area of Avon
The Coroners Court
Old Weston Road,
Flax Bourton
BS48 1UL
22 October 2025
Dear Mr Sowersby
Re: Baby Mabel Olivia Williams
Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the
death of Baby Mabel on 8 September 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 Mabel’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. The medical cause
of Mabel’s death was:
1a) Severe hypoxic ischaemic encephalopathy,
1b) Undiagnosed uterine rupture.
We also recognise the matters of concern as outlined in your letter as follows,
When Becky (Mabel’s mother) was advised about VBAC she was referred to internal guidance from
the hospital and to the RCOG’s information leaflet “Birth options after previous caesarean section”
(published in July 2016). I reviewed the information leaflet and it does not contain any indication that
uterine rupture could potentially prove fatal for mother and / or baby. My concern is that prospective
parents may rely on this information leaflet to assist them in making informed choices about their
birth options, and that if the risk is not identified then other patients like Becky might pursue VBAC in
circumstances where – if they had understood the risk better – they would have chosen otherwise.
The purpose of RCOG patient information leaflet is to convey essential information in an accessible
format. It aims to support the individualised discussion between the clinician and the woman and
their partner and/or other friends and family and is not intended to be a stand-alone resource.
All our patient information leaflets are produced in collaboration with service users and clinicians to
try to ensure that they convey information that is accurate, relevant, clear and succinct. The depth
of information is agreed after very careful consideration, and with input from service users and
clinicians, and highlights that additional conversations with clinicians are needed to help personalise
the risks for an individual.
In response to your concerns, this patient information leaflet is based on the RCOG Green-top
Guideline No 45 Birth After Previous Caesarean Birth1 (October 2015). The Green-top Guideline
states that uterine rupture is a rare but serious complication associated with maternal and perinatal
morbidity and mortality:
Women should be informed that the absolute risk of birth-related perinatal death associated with
VBAC is extremely low and comparable to the risk for nulliparous women in labour.
Women should be informed of the two-to-three-fold increased risk of uterine rupture and around 1.5-
fold increased risk of caesarean birth in induced and/or augmented labour compared with
spontaneous VBAC labour.
Approximately 0.5% risk of uterine scar rupture. If occurs, associated with maternal morbidity and
fetal morbidity/mortality.
The guideline stresses the importance of early diagnosis, expeditious laparotomy, and neonatal
resuscitation to reduce morbidity and mortality related to uterine rupture.
The guideline also recommends that decisions for induction and augmentation of labour in such
situations should be made in consultation with senior obstetric input and after informed discussion
with the woman, in recognition of the increased risks. This being an individualised discussion would
be outside of the scope of a standard patient information leaflet.
The patient information leaflet Birth after Previous Caesarean2 , while not using the precise term
‘fatal’ in relation to uterine rupture nonetheless states the risks and that stillbirth can be a serious
consequence of VBAC.
“Serious risk to your baby such as brain injury or stillbirth is higher than for a planned caesarean
section.”
“The scar on your uterus may separate and/or tear (rupture). This can occur in 1 in 200 women. This
risk increases by 2 to 3 times if your labour is induced. If there are warning signs of these
complications, your baby will be delivered by emergency caesarean section. Serious consequences for
you and your baby are rare”.
This RCOG leaflet has been reviewed and updated recently and is due for publication in the very near
future.
Counselling for VBAC is never a one-off event. Women should be counselled antenatally, with
information revisited in labour because the risk profile is dynamic, particularly where induction or
augmentation of labour is being considered. It is the clinical team’s responsibility to ensure that
women understand not only the numerical risks but also the potential consequences for mother and
baby.
It is also important to note that, under the Core Competency Framework developed by the
Maternity Transformation Programme3 and national partners, all maternity units are required to
standardise training to enhance safety and consistency in care. Module 3 specifically addresses
medical emergencies and multi-professional training, with a requirement that 90% of relevant staff
attend annual in-house MDT training (PROMPT) covering at least four maternity emergencies over a
three-year period, including uterine rupture, with priorities tailored to local needs. This framework
reinforces that the unit has a responsibility to ensure that all staff, including those managing labour,
are trained to recognise and respond promptly to emergencies such as uterine rupture.
Responsibility therefore extends beyond the individual clinician to the unit’s broader duty to
maintain competency and preparedness through mandated training.
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
References
1. RCOG GTG No 45. October 2015
2. RCOG PIL: Birth after previous caesarean, published 2016
3. NHS England Core competency framework v2: Minimum standards and stretch
targets NHS
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