Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0458, 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 | 2025-0458 |
| Deceased | Mabel Williams |
| Coroner | Robert Sowersby |
| Coroner area | Avon |
| Category | Child Death (from 2015) |
| Organisation named | Great Western Hospitals NHS Foundation Trust |
| 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 Chief Executive Great Western Hospitals NHS Trust Marlborough Road Swindon SN3 6BB 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 on 10 September 2023 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. – Background The Ockenden Report, which I was directed to in evidence, first published in 2020 a list of immediate and essential actions which included: ‘all Trusts must ensure women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean delivery.’ The externally conducted HSIB report which looked into Mabel’s death identified in February 2024 that the Trust’s guidance for patients on ‘Birth after caesarean’ did not describe what a uterine rupture is. That point was made in the context of Mabel’s parents telling the HSIB investigation that they were not informed about the possible consequences of a uterine scar rupture, or that at their most severe those consequences could include the death of their baby. I found at the conclusion of Mabel’s inquest that appropriate steps had not been taken to obtain shortcomings of the Trust’s patient information leaflets were part of what informed that finding. informed consent to VBAC, and the In advance of the inquest the Trust’s legal representatives found it difficult to provide me with current copies of relevant patient information leaflets. When they were finally disclosed (on day 3 of the inquest) I found it hard to get a clear picture of whether the leaflets were or were not ‘in force’. I heard evidence at one point from a member of trust staff that revised leaflets (which did contain a full explanation of uterine rupture) had been drafted but not signed off by the Trust for distribution to patients, much to the frustration of the maternity unit. I was also provided with an Excel spreadsheet after the inquest which contained, among other things, information about the Trust’s compliance with various objectives relating to the Ockenden Review. The information in that spreadsheet included an indication that one of the Trust’s objective was that “Change in practice arising from an SI investigation must be seen within 6 months after the incident occurred”. The spreadsheet suggested that this objective was not being achieved. This would accord with my impression (which I would have reached irrespective of having sight of the spreadsheet) that much of the change that I was being shown following Mabel’s death was coming very late, and as a response to the impending (or active) inquest, not as a result of learning from the tragic events in question. Specific concern That the Trust may not be making appropriate changes within a reasonable timeframe following serious clinical incidents. 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 5 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: Quality Commission who may find it useful or of interest. . I have also sent it to the Care 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 10 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.
3rd November 2025 The Great Western Hospital Marlborough Road Swindon SN3 6BB Private and confidential Robert Sowersby Assistant Coroner for the Coroner Area of Avon Dear Mr Sowersby, Re: Coroner’s Regulation 28 Report – Mabel Olivia Williams We write in response to the Regulation 28 Prevention of Future Deaths Report, raising concerns about the circumstances which led to the tragic death of Mabel Olivia Williams. I would like to express my deepest condolences to Mabel’s family and acknowledge the distress this process has caused. Thank you for the clarity and detail of your report. We recognise the seriousness of the concerns you have raised and are committed to addressing them with the utmost care and diligence. Please find below a summary of the actions taken to date, alongside the improvements that are currently in progress and those planned for the near future. In September 2023 a Patient Safety Review into Mabel’s case was undertaken which reviewed the entirety of the care Becky and Mabel received to identify opportunities for learning. Mabel’s birth was reported to the Maternity and Newborn Safety Investigation (MNSI) team for an external review, and eight safety recommendations were identified in February 2024. An improvement plan was developed based on these recommendations with a focus on addressing the actions identified. Patient Information and Informed Consent You identified that the Trust’s patient information leaflets did not describe what a uterine rupture is, particularly in the context of VBAC (Vaginal Birth After Caesarean). You have found that this contributed to Becky not having enough information to give informed consent to a VBAC. You further noted that the Trust’s processes for updating and distributing these leaflets were unclear. Actions Taken: The Trust has undertaken a comprehensive review of the “Birth After Previous Caesarean” patient information leaflet. The revised leaflet now provides a clear, accessible explanation of uterine rupture, including its potential severity and the associated risks to both mother and baby which includes the risk of the death of the baby. This updated leaflet is now available to all clinical staff and is provided to women considering their birth options in addition to counselling in relation to these options. This is provided to women in the appointment when they meet their named Consultant to discuss the birth of their baby. The Trust places the utmost importance on delivering personalised care, ensuring that women and their families feel genuinely heard, respected, and supported throughout their care. Central to this commitment has been the development of a perinatal education programme, co-produced with our Maternity and Neonatal Voices Partnership, which emphasises the importance of actively listening to women. Through this collaborative approach, we ensure that all women receive clear, accessible, and comprehensible healthcare information as an essential part of the consent process. As part of our ongoing commitment to quality and patient safety, the Trust has undertaken a comprehensive review of its procedures for the approval, distribution, and audit of all patient information leaflets. This initiative ensures that only the most current and formally approved versions are in circulation, and that these materials are easily accessible to both staff and patients. By strengthening these processes, we aim to support informed decision-making and enhance the overall patient experience. The Trust is prioritising moving to an online hosting system which will ensure that the public have access to all of the Trust patient information leaflets via the hospital website. Timely changes in clinical practice You raised concerns regarding the timeliness with which changes in clinical practice are implemented following serious incidents, and you have noted that this objective was not being achieved on the Trust’s spreadsheet as to compliance with the Ockenden recommendations. The Trust has provided a detailed update outlining its current position in relation to the Ockenden review, including the status of all Immediate and Essential Actions and projected completion dates. This was submitted within the designated timeframe following the inquest. It is noted that all the Red actions i.e. the urgent actions arising from the Ockenden report have already been completed by the Trust. We fully acknowledge the importance of ensuring that learning from serious incidents is translated into practice both promptly and sustainably. To that end, we are undertaking a review of our governance processes to strengthen oversight and accountability for the implementation of learning and improvement actions. Actions taken In response to the concerns raised, a full review was undertaken of all outstanding actions from the Trust’s serious incident investigations to fully establish the current compliance position and ensure that learning is being translated into meaningful and timely change. To support continued oversight, these actions are reviewed within our monthly Maternity Governance meetings, enabling senior leaders to monitor progress, escalate concerns, and ensure accountability. To ensure that learning is not only captured but acted upon in a timely and sustained way, we have strengthened our internal systems for tracking and monitoring progress and this revised governance process will be fully embedded by December 2025. Outstanding actions from the Trust’s serious incident investigations are now held within a centralised platform that supports teams with timely prompts and clear visibility of responsibilities. Colleagues across the organisation have been asked to contribute evidence of progress, reflecting our shared commitment to transparency and improvement. Weekly meetings with the Patient Quality, Safety and Assurance team provide a dedicated space to review developments, address any barriers, and maintain collective momentum in delivering meaningful change. The Trust has reflected deeply on the experience shared by the family, particularly their feeling of not being listened to and their concerns around the process of informed consent. We recognise the profound impact this has had and are committed to ensuring that every individual in our care feels heard, respected, and fully informed. We remain firmly committed to listening in a compassionate and comprehensive manner, ensuring that patients and families fully understand the care being proposed and feel supported throughout their journey. The Trust is committed to ensuring that the lessons from this tragic case contribute to meaningful and lasting improvements in the safety and quality of our maternity and neonatal services. Once again, I wish to extend my sincerest condolences to Mabel’s family and to apologise unreservedly for the distress experienced. Yours sincerely Chief Executive Great Western Hospitals NHS Foundation Trust, Royal United Hospitals Bath NHS Foundation Trust, Salisbury NHS Foundation Trust Copy to: Chief Coroner, Care Quality Commission
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