Mohammed Khan

11 November 2025 

Association of Ambulance Chief Executives 
25 Farringdon Street 
London 
EC4A 4AB 

Ms Emma Brown 
Area Coroner for Birmingham and Solihull 

Dear Ms Brown 

MOHAMMED ISMAIL KHAN (DECEASED) 

I am writing in response to the preventing future deaths report issued to our executive officer at the 
Association of Ambulance Chief Executives (AACE), and I respond as our Director of Operational 
Development and Quality Improvement on behalf of AACE. 

On behalf of AACE, I would like to extend our sincere condolences to the parents and family of 
Mohammed Ismail Khan. 

It may be helpful for us to explain that AACE is a private company owned by the English and Welsh 
Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that 
supports, co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing 
development of the English ambulance services and the improvement of patient care. It is a company 
owned by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges 
Ambulance Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines (the 
“JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services however it 
has national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along 
with a network of national specialist sub-groups.  

We respond by providing comments to your matters of concern relating to ambulance clinical 
guidelines (JRCALC) and training and education of ambulance staff. We recognise and acknowledge 
that breech birth is a high acuity, low occurrence presentation to ambulance staff and that ideally a 
woman should be in a hospital obstetric unit to have her baby.  

The JRCALC guidelines are advisory and have been developed to assist paramedics make decisions 
about the management of the patient’s health, including treatments and to support clinical practice. 
The advice is intended to support the decision-making process and is not a substitute for sound 
clinical judgement. We recognise that the guidelines cannot always contain all the information 
necessary for determining appropriate care and cannot address all individual situations; therefore, we 
expect that paramedics using JRCALC guidelines ensure they have the appropriate knowledge and 
skills to enable suitable interpretation. 

The JRCALC guidelines contain guidance on the assessment and management of maternal 
emergencies, and we have a specific guideline for breech birth. The guideline was updated in 
September 2023 following extensive review by obstetricians, midwives, and paramedics. During the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 review we reviewed the available published clinical evidence around breech birth management and 
also considered reviews and outcomes of known incidents of breech births in the prehospital 
environment. We found that the published clinical evidence and guidance available was mainly 
hospital based and written predominantly for midwives and obstetricians.  

We took a consensus approach to our guidance as it needed to be written for paramedics who may 
have not had clinical experience of a breech birth due to its low incidence in the prehospital 
environment. The aim was to ensure that the guidance was as simple, clear, and easy to use as 
possible. As part of the process, we asked a number of paramedics to review the management of 
breech birth algorithm for its ease of use and whether it was clear to them if they were to use it in an 
emergency situation. We also built into the guidance photographic images using mannequins to help 
show the specific manoeuvres that we recommend to deliver the baby and in addition we included 
short video clips.  

The guidance details when to consider moving the mother to hospital, how to position the mother and 
how to support delivery of the baby. It is a difficult decision in a highly stressful situation to decide to 
try and move the mother to hospital if she is in in the process of delivering her baby and if a visible 
part such as limb has been delivered but delivery of the head is delayed. We provide guidance on this 
and emphasise the time critical nature of a breech birth delivery and that ideally the mother should be 
in an hospital obstetric unit. We have received feedback through our networks that since we issued 
the revised guidance it is helpful and that it has been used to support the delivery of breech babies.  

With regard to your matter of concern around the training and education of paramedics, AACE are not 
responsible for this. However, we have shared the report via our networks and specifically with the 
national education network for ambulance trusts (NENAS), with the national pre-hospital maternity 
and newborn care group and the national ambulance services medical directors’ group (NASMeD) for 
them to consider your matters of concern in their own organisations.    

With regard to under-graduate and post-graduate paramedic training we are aware of variation in the 
provision of training for paramedics in maternity care and breech birth in both Universities (accredited 
by the HCPC) and ambulance services which for qualified paramedics is the responsibility of 
individual ambulance trusts. Additionally, we do not have any control over the allocation of specific 
funding for maternity training. We are aware that some training is delivered face-to-face to staff, often 
supplemented by online modules, webinars, and instructional videos. Simulation and hands on 
practice are widely used with training covers both theoretical and practical skills. Refresher training 
varies with some services offering training every 1-4 years, annually or as a part of continuous 
professional development.  

If you have any further questions, please do not hesitate to contact us again. 

Yours sincerely 

Director of Operational Development and Quality Improvement

NHS Birmingham and Solihull 
8th Floor Alpha Tower 
Suffolk Street Queensway 
               Birmingham B1 1TT 

NHS Black Country ICB 
Civic Centre 
                      St Peter’s Square 
Wolverhampton 
 WV1 1SH 

30 October 2025 

Ms Brown 
Senior Coroner for Birmingham and Solihull 

Dear Ms Brown, 

Inquest concerning the death of Mohammed Ismail Khan.  

Response to Regulation 28 of the Coroners (Investigations) Regulations 2013. 

I  am  writing  in  response  to  the  Regulation  28  notice  issued  following  the  conclusion  of  the 
investigation into the death of Mohammed Ismail Khan on the 4th September 2025, who sadly died 
on the 6th September 2022.  

I extend my sincere condolences to Mohammed’s family and friends.  

We acknowledge the serious concerns raised regarding findings from the WMAS investigation which 
concluded  that  the  national,  JRCALC  guidelines  for  the  clinical  assessment  and  management  of 
breech birth were not adhered by the paramedics and regional trauma desk, and the importance of 
taking meaningful action to prevent future deaths. 

NHS Birmingham and Solihull (BSOL ICB) has carefully considered the issues outlined in your report 
and will work closely with Black Country ICB who will coordinate a single, collective response to the 
Regulation 28 notice on behalf of all West Midlands ICBs by 11th November 2025.  

The ICB takes the recommendations within the Regulation 28 report extremely seriously. We are 
committed to support Black Country ICB and WMAS in delivering the necessary improvements to 
the service and we recognise the importance of learning from this tragic event to help prevent similar 
incidents in the future.  

If we can be of any further assistance at this time, please do not hesitate to contact me. 

Yours Sincerely  

Chief Executive Officer 
Birmingham & Solihull & Black Country Integrated Care Board

Ambulance Service Headquarters 
Waterfront Business Park 
Brierley Hill 
West Midlands 
DY5 1LX 

Ms Brown     
Area Coroner for Birmingham and Solihull 
50 Newton Street 
Birmingham 
B4 6NE 

10 November 2025 

Dear Ms Brown 

Re: Mohammed Ismail Khan  

Thank you for your email dated 16 September 2025 attaching your Regulation 28 Report.  

On behalf of West Midlands Ambulance Service (WMAS), I am sorry that you have had to raise 
concerns following the Inquest of Mohammed.  May I please take this opportunity to pass on my 
sincere condolences to the family of Mohammed. I am deeply saddened by this case. 

Please see our response to your concerns. 

Concern 1 

,  West  Midlands  Ambulance  Service  (‘WMAS’)  Clinical  Manager  Maternity 
Lead  -  gave  evidence  regarding  the  findings  of  WMAS  Serious  Incident  Investigation.  She 
explained: 

a. At 18:55 on the 06.09.22 the trust received a 999 call for Mohammed’s mother, Mrs Khan, who 
was  36  weeks  pregnant  and  it  was  reported  the  baby  (Mohammed)  was  being  born  feet  first.   

b. A category 1 disposition of “Emergency Ambulance Response for Obstetric Complications” was 
reached. 

c.  At  18:58,  the  1st  double  crewed  ambulance  (DCA)  resource  was  dispatched  and  arrived  at 
19:07, a further DCA and Operations Manager also attended.   

d. The clinicians in attendance had no prior experience of breech deliveries.  

1 | P a g e  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 e. They advised Ms Khan to move from standing to all 4s and this progressed the delivery a little, 
visible parts of the baby were indicative of hypoxia, and the umbilical cord was white and non-
pulsing. They followed a ‘hands off’ approach and sought advice from the regional trauma desk 
who advised rapid transfer to hospital and had pre-alerted Birmingham Heartlands Hospital (BHH).  

f. The crew left at 19:20 and arrived at BHH at 19:24. The patient was admitted to theatre at 19:26 
and  following  Lovsett's  maneuver  Mohammed  was  born  at  19:27  with  no  heart  rate  and  no 
respiratory  effort.  Although  he  responded  to  resuscitation,  he  had  suffered  profound  severe 
hypoxic ischemic brain damage. 

Response 

 gave evidence to suggest Mohammed had been presenting as feet first (footling 
breech) for 7 minutes prior to the 999 call being made. When the clinicians arrived on scene, he 
had descended up to his waist and they immediately asked his mother to go onto all-fours to try 
to aid birth. This helped the birth progress to his naval, but when the birth did not progress further, 
a  decision  was  made  to  immediately  transfer  Mum  and  Mohammed  as  the  clinicians  felt  they 
would  be  unable  to  manage  this  safely  on  scene.  Attempting  to  assist,  would  have  caused  a 
greater delay on scene. 

It is noted that Mohammed was born using the Lovesett’s manoeuvre. At the time of the incident, 
the paramedic breech birth algortihm did not provide sufficient detail on how to perform the full 
manoeuvre. The guidance has since been updated to make it clear and allow paramedics to use 
this manoevre safely and effectively when needed.  

The new guidance also includes additonal pictures, videos and step-by-step advice on what to do 
when birth is imminent or not imminent, how to position the mother and when and how to use 
certain manoeuvres if required. 

Concern 2  
The  WMAS  investigation  concluded  that  the  national,  JRCALC  guidelines  for  the  clinical 
assessment and management of breech birth were not adhered by the paramedics and regional 
trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention 
to aid delivery should be attempted. 

Response 
As stated during the evidence given, at the time of the incident, the national guidance was for 
delayed  breech  births  to  be  assisted  with  additional  manoeuvers  as  described  on  the  WMAS 
Maternity  Action Card. The Action Card was missing from the first ambulance, but a clinician from 
the  second  ambulance  had  a  card  in  their  pocket  which  was  followed  until  the  birth  failed  to 
progress past the naval. The information on the card after this point was imprecise which led to a 
decision  being  made  to  immediately  convey  Mum  and  Mohammed  to  a  place  of  specialist 
maternity care which was provided at Birmingham Heartlands Hospital. 

This  card  has  now  been  removed  from  all  Trust  vehicles,  the  Regional  Trauma  Desk  and 
destroyed. A Clinical Notice has also been distributed to ensure all clinicians destroy any WMAS 
Maternity Action Cards in their possession.  

2 | P a g e  

 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 3 
Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide 
much better assistance 
 explained that it is not mandatory for paramedics to receive 
specific  training  on  obstetric  emergencies,  including  breech  delivery,  either  in  their  foundation 
training/education or as part of continuing professional development. 

Response 
 has stated her 
We firstly apologise if the evidence given has caused confusion, 
evidence  regarding  mandatory  training  was  in  relation  to  University  training,    which  is  where 
content delivery may differ, not the training West Midlands Ambulance Service provides. 

Training for obstetric emergencies is provided within The Level 4, 5 and 6 Associate Ambulance 
Practition (AAP) Programme which is a regulated training programme for all student paramedics 
on the apprenticeship pathway employed by WMAS.  

The Graduate Paramedic Programme is a clinical induction for all newly qualified paramedics who 
have  been  employed  by  WMAS  but  have  completed  their  training  with  a  University.  Graduate 
Paramedics  must  complete  this  programme  in  order  to  be  able  to  work  operationally  on  an 
ambulance. 

Within the Level 4 AAP Programme and the Graduate Paramedic Induction programme obstetric 
emergencies including breech birth are covered in the content summarised below: 

-  Overview of breech birth 
-  Types of breech presentation 
-  Risk factors 
-  Current JRCALC algorithms 
-  Management of complications 
-  Criteria for rapid transport 
-  Transport and conveyance considerations and positioning 

The Trust invested in 5 “Victoria” mannequins at a cost of £69,000 each at the end of 2023 making 
simulation  more  realistic.  These  state  of  the  art  simulators  are  unique  in  their  ability  to 
autonomously simulate childbirth and integrate seamlessly with the Trust’s Zoll Series monitor 
enabling real-time monitoring of the mother’s vital signs during training scenarios. Victoria offers 
ambulance  staff  the  most  realistic  and  immersive  training  exeriences  for  handling  all  obstetric 
emergencies including breech birth. 

Practical  sessions  have  also  been  timetabled  into  the  AAP  course  and  Graduate  Paramedic 
Induction  Programme,  allowing  learners  to  simulate  breech  births  using  the  Victoria  birthing 
mannequins, as well as other maternity training equipment such as birthing pelvises and training 
babies. These sessions were updated in 2023 following the new guidance. 

A Clinical Supervision shift (CS1) is mandatory for all ambulance clinicians and during this shift 
planned in the year 2024/25, staff were informed to review the new JRCALC guidance on breech 
delivery. 

3 | P a g e  

 
 
 
 
 
 
 
 
 
 
 
 
 
 West Midlands Ambulance Service clinicians partake in yearly refresher mandatory training both 
face to face in a classroom and online. Prior to this PFD being issued discussions and planning 
had taken place to include obstetric emergencies including breech birth within next year’s 2026/27 
face to face mandatory training. 

In addition, planning began in August 2025 to refresh the Trust’s local priorities for the Patient 
Safety Incident Response Framework (PSIRF) to include Obstetric Emergencies encompassing 
breech births. 

Concern 4 
The  clinicians  who  attended 
techniques advised by JRCALC even if they had realised they were advised. 

  said  they  would  not  have  felt  confident  to  attempt  the 

Response 
As presented by 
 in her evidence, it is recognised that ambulance clinicians do 
not  frequently  attend  obstetric  emergencies  which  could  lead  to  staff  lacking  in  confidence  to 
manage these cases.  

The Trust has a Risk Assessment in place which is reviewed on an annual basis to identify any 
gaps or further learning opportunities. 

The clinicians involved in this case attended supportive remedial training specifically focused on 
breech birth. 

Concern 5 

ambulance responses. 

 explained that maternity and obstetric care makes up 3 per cent of emergency 

Response 
Following the recommendations of the Ockenden Report, in December 2022, 
arranged  for  paramedics  to  attend  Birmingham  Women’s  Hospital  for  observation  shifts. 
Unfortunately due to staffing shortages within midwifery, this was paused by the maternity unit. 

The  Trust  has  put  multiple  measures  in  place  to  provide  Continual  Professional  Development 
(CPD)  to  our  staff  including  well  attended  “Maternity  Roadshows”  led  by 
  in 
September  and  October  2023  where  a  Victoria  mannequin  was  utilised  to  simulate  births  and 
obstetric  emergencies  supported  by  the  Maternity  Champions.  In  September  2023,  we  held  a 
themed Maternity Month where Maternity Roadshows were held with 9 expert guest speakers. 
On October 9th 2024, one of the guest speakers was a Breech Specialist Midwife from Birmingham 
Women’s Hospital who demonstrated a live breech birth simulation using a Victoria mannequin. 

Health Education England awarded the trust funds to invest in  5 “Victoria” mannequins at a cost 
of  £69,000  each  at  the  end  of  2023  making  simulation  more  realistic.  These  state  of  the  art 
simulators are unique in their ability to autonomously simulate childbirth and integrate seamlessly 
with the Trust’s Zoll Series monitor enabling real-time monitoring of the mother’s vital signs during 
training  scenarios.  Victoria  offers  ambulance  staff  the  most  realistic  and  immersive  trainin 
exeriences for handling all obstetric emergencies including breech birth. 

4 | P a g e  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 As  presented  in 
  evidence,  in  2023  the  Trust  implemented  Maternity 
Champions to share learning opportunities and support staff who lack in confidence, there is at 
least  one Maternity Champion on each operational hub. 

The  Trust  published  a  special  edition  of  the  Clinical  Times  in  August  2024  called  “Maternity 
Matters”  which  included  information  on  maternal  assessment  as  well  as  some  obstretric 
emergencies.  

On the 3rd September 2024, the first National Pre-Hospital Maternity and Newborn Conference 
was held in Birmingham which was attended by our Trust midwife and 14 maternity champions 
highlighting the Trust’s commitment to advancing safe maternity care. 

In response to the Ockenden Report, a “Maternity Action Plan” was devised to provide a summary 
of  the  Trust’s  response  to  new  local  and  national  maternity  practice.  This  action  plan 
demonstrates that robust actions are consistently being taken to ensure maternity services WMAS 
provide  are  safe  and  robust.  A  number  of  recommendations  are  suggested  and  are  ongoing, 
including to create maternity CPD training videos. This paper is reviewed and re-presented twice 
a year. 

The Trust has implemented emergency “red pre-alert phones” in all 15 maternity units across the 
region, these phones allow our clinicians to seek immediate help if on scene with an obstretric 
emergency requiring immediate transportation. The use of these phones was promoted during 
World Patient Safety Day 2025 along with the Pre-Hospital Maternity Decision Tool.  

The Trust has also proposed a local priority for April 2026-April 2027 under the Patient Safety 
Incident Response Framework (PSIRF) that will focus on obstetric emergencies including breech 
birth falling outside of the Maternity and Neonatal Safety Investigations (MNSI) criteria. 

Whilst  partaking  in  World  Patient  Safety  Day  2025  where  the  theme  was  “Safe  care  of  every 
newborn and every child” the Trust celebrated the use of the Transwarmer which is a device used 
to  support  thermoregulation,  this  had  been  recognised  as  an  “excellent  theme”  demonstrating 
improvement within obstetric emergencies. 

Concern 6 
Whilst WMAS have purchased specific training equipment and an online course for clinicians on 
the  management  of  obstetric  emergencies  in  response  to  the  findings  of  the  investigation, 
resourcing is such that it has not been possible for all paramedics to receive this additional training 
e.g. less than a third of paramedics with WMAS have completed the online course. 

Response 
At the time of the Inquest, the e-PROMPT course was paused due to updates and changes in 
national guidance so our clinicians could not complete this additional training. This was not due 
to resourcing. The course has now been relaunched and on 16th October 2025 our Education and 
Training Department advertised this in our Weekly Briefing and clinicians can now complete this. 

5 | P a g e  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Health Education England awarded the Trust funds to invest in 5 “Victoria” mannequins at a cost 
of £69,000 each towards the end of 2023 making simulation more realistic. These state of the art 
simulators are unique in their ability to autonomously simulate childbirth and integrate seamlessly 
with the Trust’s Zoll Series monitor enabling real-time monitoring of the mother’s vital signs during 
training  scenarios.  Victoria  offers  ambulance  staff  the  most  realistic  and  immersive  trainin 
exeriences for handling all obstetric emergencies including breech birth. 

West  Midlands  Ambulance  provides  regulated  training  that  includes  Breech  Birth  within  the 
Associate  Ambulance  Practitioner  Course  (AAP)  and  training  within  the  Graduate  Paramedic 
Induction Programme which must be completed prior to being an operational paramedic. 

Mandatory face to face refresher training for all ambulance clinicians on obstetric emergencies 
including breech birth will be included in the programme for 2026-2027. 

Concern 7 

 evidence was that in her opinion the absence of any mandatory training on obstetric 

emergencies was putting lives at risk. 

Response 
It is 
  professional opinion, the absence of nationally mandated annual refresher 
training  on  obstetric  emergencies  affects  the  confidence  and  competence  of  clinicians  in 
managing these emergencies. She emphasised that this represents a national issue within the 
profession rather than a matter specific to WMAS. 

Operational staff have access to the JRCALC clinical guidelines, which provide evidence-based 
guidance for the management of obstetric emergencies. These guidelines are readily available 
and regularly updated. 

 used the term to 
When using the term mandatory training during her evidence 
mean training in relation to University training. 
 recognises that mandatory training could 
also be interpreted to mean mandated annual refresher training outside the ambulatory sector. 
 apologises if her use of the term was not made clear during her evidence. While there 
is  no  standalone  mandatory  module  specifically  for  obstetric  emergencies,  relevant  content  is 
incorporated  into  broader  clinical  refresher  training  and  continuous  professional  development. 
This ensures that staff remain competent, confident, and able to manage such cases safely and 
effectively. 

Since this incident we have implemented a number of actions as described above but noteably: 
-  Face  to  face  mandatory  refresher  training  has  been  included  for  2026-2027  that  will 

include breech birth. 

-  Resumption of the e-PROMPT course. 
-  A  Trust  focus  on  learning  and  improvement  of  obstetric  emergencies  with  a  proposed 

PSIRF priority covering this area. 

-  Removal  and  destruction  of  out  of  date  WMAS  Maternity  Action  Card  from  all  Trust 

Vehicles. 

6 | P a g e  

 
 
 
 
 
 
 
 
 
 
 
 
 -  A  Clinical  Notice  to  all  clinical  staff  advising  them  to  remove  the  out  of  date  WMAS 

Maternity Action Card from their possession and destroy it. 

It is hoped that  the above information provides you with assurance that WMAS includes obstetric 
emergencies within mandatory training alongside multiple other areas to promote safe maternity 
care within our organisation and that patient safety is our priority. 

Once again please pass on  our sincere condolences to the family of Mohammed Khan.  We are 
sorry we let Mohammed and his family down.  

If you require any further information, please do not hesitate contact us. 

Your sincerely, 

Clinical Manager - Maternity Lead / Trust Midwife 

Director of Nursing 

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