Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0543, written 27 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Oct 2025 |
|---|---|
| Reference | 2025-0543 |
| Deceased | Louisa Walker (1) |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Officer, Royal College of Obstetricians and Gynaecologists 1 CORONER I am Mrs H J Connor, Senior Coroner for the coroner area of Berkshire. 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. It is important to note the case of R (Dr Siddiqui and Dr Paeprer-Rohricht) v Assistant Coroner for East London. This case clarifies that the issuing and receipt of a Regulation 28 report entails no more than the coroner bringing some information regarding a public safety concern to the attention of the recipient. The report is not punitive in nature and engages no civil or criminal right or obligation on the part of the recipient, other than the obligation to respond to the report in writing within 56 days. 3 INVESTIGATION and INQUEST I conducted an inquest into the death of Louisa Walker which concluded on 23rd of October 2025. I recorded a narrative conclusion as follows: Louisa’s death was the direct result of a resident doctor performing a manoeuvre to try to disimpact her head during a caesarean section, which caused skull fractures and intracranial haemorrhage. 4 CIRCUMSTANCES OF THE DEATH Louisa’s head was noted to be impacted in her mother’s pelvis during a caesarean section. She suffered skull fractures and intracranial bleeding as a result of the manoeuvres used to dismpact her head. She was born on 25th May 2024, and died on 28th June 2024. References were made throughout the inquest to the fact that there is no green top guideline for this obstetric emergency. I understand that the RCOG scientific impact paper number 73 has been retracted (for largely unrelated reasons). The algorithm referred to in that paper had been adopted by the trust in this case – and that may perhaps be the case in other hospitals – but there is currently no national guidance on dealing with impacted fetal head. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: (brief summary of matters of concern) Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. There is no national guidance (by way of green top guideline or otherwise) dealing with impacted fetal head seen at caesarean section. 2. Whilst the algorithm referred to on RCOG scientific impact paper number 73 may well have been adopted by many trusts, there is a risk of uncertainty and absence of relevant training in respect of this obstetric emergency. I understand that impacted fetal head is becoming increasingly common. 3. 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 22nd of December, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to Louisa’s family. I have also sent this report to the following recipients who have an interest in this matter: 1. Legal representative for Royal Berkshire Hospital Trust. 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 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 by the Chief Coroner. 9 Dated: 27th of October 2025 Heidi J Connor Senior Coroner for Berkshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
Maternity & Newborn Safety Investigations Care Quality Commission 2 Redman Place London E20 1JQ Date: 07/01/2026 Dear Mrs Connor, Louisa Walker: inquest 22nd and 23rd of October 2025 Thank you for your letter, dated 27/10/2025, with a copy of the Record of Inquest and a copy of the report of an independent expert ( ). The inquest record and independent report were shared with our investigation team, who have reviewed the MNSI report ( was correctly followed, including discussions around the management of the birth. ), process and findings, to ensure that the investigation process Our team have concluded that our investigation process was correctly followed, using the evidence provided, via health records and interviews during their investigation, to inform the findings. We have ensured that a note has been added to our investigation record to highlight the findings of the inquest, specifically the difference in the inquest conclusions and those in our original report. Thank you again for taking the time to share your findings. Yours Sincerely, MNSI Governance Manager CC: MNSI Programme Leadership Team
Heidi J Connor His Majesty’s Senior Coroner for the Coroner area of Berkshire Reading Museum and Town Hall, Blagrave Street, Reading, RG1 1QH 3 March 2026 Dear Ms Connor Re: Baby Louisa Walker Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Louisa dated 27 October 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 Louisa’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. Louisa’s head was noted to be impacted in her mother’s pelvis during a caesarean section. She suffered skull fractures and intracranial bleeding as a result of the manoeuvres used to disimpact her head. We also recognise the matters of concern as outlined in your letter as follows: 1. There is no national guidance (by way of green top guideline or otherwise) dealing with impacted fetal head seen at caesarean section. 2. Whilst the algorithm referred to on RCOG scientific impact paper number 73 may well have been adopted by many trusts, there is a risk of uncertainty and absence of relevant training in respect of this obstetric emergency. 3. I understand that impacted fetal head is becoming increasingly common. In response to your concerns, we acknowledge that impacted fetal head at caesarean birth is an increasingly encountered obstetric emergency, potentially complicating one in ten unplanned caesarean births, and around 1.5% of all births. It carries significant maternal and neonatal risk. The rise in reported incidence may be due to better recognition of the emergency and rising caesarean birth rates in the United Kingdom, but the exact reason Page 1 of 3 remains uncertain. We agree that greater consistency in national guidance is necessary, and variation in training may contribute to risk. In recognition of this, impacted fetal head at caesarean birth was included as one of the two components of the recently concluded Avoiding Brain Injury in Childbirth (ABC) Programme. The ABC programme was commissioned by the Department of Health and Social Care in 2018, as a national maternity safety initiative, and concluded its pilot phase and third iteration in 2025. It was developed collaboratively by the RCOG, the Royal College of Midwives and The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, with crucial input from service users and frontline clinicians. It focuses specifically on reducing avoidable intrapartum brain injury, including through the safe management of impacted fetal head at caesarean birth. The programme combines evidence-based clinical standards with structured multidisciplinary training and practical tools. It uses a “train-the-trainer” cascade model to help embed consistent practice locally. It emphasises both technical and non-technical skills, including communication, teamwork and situational awareness. Following the pilot phase, NHS England is now rolling out the ABC programme nationally across all maternity services in England. This national implementation is intended to reduce unwarranted variation in care and support maternity units in strengthening preparedness for managing impacted fetal head. The training that each unit will receive includes clear step by step guidance for the management of impacted fetal head which will be implemented within all units. RCOG Scientific Impact Paper No. 73, Management of Impacted Fetal Head at Caesarean Birth (2025 Second Edition), was produced as part of the ABC programme. It provides a working definition of impacted fetal head, reviews the current evidence regarding prediction, prevention and management, and describes the recognised techniques for managing the emergency. Scientific Impact Papers (SIPs) are used where the evidence base is still evolving and insufficient to support a formal Green-top Guideline. While Green-top Guidelines aim to provide clinical instructions, SIPs give expert analysis on the new scientific findings and highlight the future implications on practice. Although a SIP does not carry the status of a Green-top Guideline, it is a formal, peer-reviewed RCOG publication intended to inform national standards and practice. The 2025 second edition was developed to reflect current evidence and clarify its strengths and limitations. We will continue to review emerging evidence and consider guideline development when the evidence base permits. The Scientific Impact Paper explicitly recognises that variation in practice and lack of structured, multi-professional training may contribute to avoidable harm. It sets out detailed descriptions of safe technique, which have contributed to the development of step- by-step guidance to manage the emergency. It emphasises that these techniques require effective training and rehearsal, ideally through simulation, and that clear communication within the theatre team is essential. These elements have been incorporated into the ABC Page 2 of 3 programme mentioned above and will be taught to maternity units in England as part of the national roll out of the ABC programme, with the explicit aim of reducing poor outcomes for mothers and babies who experience this emergency. There is currently an active programme of national rollout of the ABC programme by NHSE. Once again, we offer our deepest condolences to Louisa’s family, and we 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 3 of 3
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