Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0544, 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 | 2025-0544 |
| Deceased | Louisa Walker (2) |
| Coroner | Heidi Connor |
| Coroner area | Berkshire |
| Category | Child Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Royal Berkshire 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Chief Executive at Royal Berkshire Hospital 1 CORONER I am HEIDI 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. The trust’s own investigation action plan highlighted a need for training around impacted fetal head scenarios, following the tragic death of Louisa. The trust served a statement from a senior patient safety lead for the maternity department which stated: “Our department has taken this matter very seriously and is committed to learning and changing our practice to avoid recurrence of a similar incident.” At the time of the inquest, it was almost 18 months since Louisa’s birth and death. The trust was aware that evidence would be required at the inquest regarding their action plan, and that this evidence would be given not just to the coroner, but in the presence of Louisa’s parents. Despite this, we heard in evidence that only 17% of obstetricians have undergone this further training. I understand the training is around 30-60 minutes in duration. 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. If the trust is taking this matter very seriously and is committed to learning, I am concerned that 83% of their obstetricians have not undergone this training. For the avoidance of doubt, the training referred to is training arising out of this incident, and not standard obstetric training on this issue, provided before Louisa’s death. 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 22 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. 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: 27/10/2025 HEIDI J CONNOR Senior Coroner for Berkshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Sent via Email NHS Royal Berkshire NHS Foundation Trust Chief Executive’s Office Royal Berkshire Hospital Level 4, Main Entrance London Road Reading Berkshire RG1 5AN 05th December 2025 Dear Mrs. Connor Thank you for your Regulation 28 report dated 27th October 2025 concerning the death of Louisa Walker who died on 28th June 2024. I would like to take this opportunity to express my deepest . The Royal Berkshire Foundation Trust condolences to Louisa’s parents (RBFT) is committed to learning from deaths and improving patient safety. Please find below the trust’s response in relation to the prevention of future deaths report. Matter of Concern: 1) If the trust is taking this matter very seriously and is committed to learning, I am concerned that 83% of their obstetricians have not undergone this training. For the avoidance of doubt, the training referred to is training arising out of this incident, and not standard obstetric training on this issue, provided before Louisa’s death. Impacted Fetal Head (IFH) training The Impacted Fetal Head (IFH) training referred to in the PFD was developed locally for midwives and doctors in response to this incident, as the department recognised the need for urgent training. It was deemed too long to wait for the Royal College of Obstetricians and Gynaecologists (RCOG) ‘ABC’ (Avoiding Brain Injury in Childbirth) training, which is due to be implemented early in 2026. Training in managing IFH is undertaken throughout Obstetric training, and all Consultants are deemed competent to manage this scenario by the completion of their training. Following the inquest we have now ensured that all obstetric doctors (ST1 and above Resident Doctors and Consultant Obstetricians) and all band 7 delivery suite and maternity clinical co- ordinator midwives have been trained in managing IFH which includes how to safely disimpact the fetal head vaginally and considering various manoeuvres abdominally. A training plan was drawn up by the maternity team and can be found in appendix 1. As of 24th November 2025, 100% of these groups have completed the training. The training sessions have allowed for multi-disciplinary hands-on training for those who have attended and has increased the awareness of IFH. There will also continue to be ongoing monthly drop-in sessions for hands-on training for other staff as well as doctors who may wish to practice their skills. We have an ACP (Advanced Care Practitioner) in the trust who is part of the regional team involved in training and implementing the upcoming RCOG ABC IFH training and will be responsible for training the Practical Obstetric Multi-Professional Training (PROMPT) faculty locally with a plan for IFH training to be implemented into the routine PROMPT schedule from early next year. 1 NHS Royal Berkshire NHS Foundation Trust Review of Governance processes The governance processes for oversight and management of action plans have been reviewed by the maternity team and are now integrated into the draft wider Patient Safety Incident Response Framework Plan. As detailed in Appendix 2, this revised framework ensures that all incidents, complaints, and claims are captured from various channels, aligned at Trust level, and systematically reviewed at the Maternity Governance meeting for appropriate oversight and accountability. Action plans are discussed monthly at the Maternity Risk meeting, with progress monitored via the Datix system. Escalation of issues and assurance of completed actions are tracked through Maternity Clinical Governance, Urgent Care Group Governance, and Trust-level Quality Governance Committee, with final oversight by the Board Quality Committee. I trust this has provided the required assurance in relation to the changes that have been implemented within both the speciality and Trust wide governance processes in order to improve patient safety. Please do not hesitate to contact me should you need any further information. Yours sincerely Chief Executive Officer Appendices Appendix 1 Appendix 2 Page 4 Page 6 2 NHS Royal Berkshire NHS Foundation Trust Appendix 1 Training lesson plan Impacted Fetal Head Trainer/ training provider: Maternity Education Team and Obstetric Consultant Date: November 2025 Course: Impacted Fetal Head Training Workshop Duration: 30-60 minutes dependant on group size Staff group targeted: Obstetric Consultants and SAS doctors All other Obstetric resident doctors ST1-ST7 Band 7 Midwife Delivery Suite Coordinators and Maternity Clinical Coordinators Requirement: PFD 100% compliance (Training is open to all MDT including anaesthetic, obstetric and theatre staff. Topic: Impacted Fetal Head at Caesarean Birth Aim of the training session: The aim of this session is to improve the recognition and management of Impacted Fetal Head and teach a safe vaginal disimpaction technique. Training objectives: (cid:127) Familiarity with local guidelines for management of IFH including escalation and knowledge of the algorithm (cid:127) Understand risk factors for IFH (cid:127) Understand the complications that can arise from IFH (cid:127) Understand IFH is a time-critical emergency (cid:127) The emergency needs to be declared (cid:127) Different steps that can be taken including tocolysis, higher uterine incision and additional uterine incisions (cid:127) Manoeuvres. Opportunity to watch videos and practice - Push techniques 1. Vaginal disimpaction 2. Fetal pillow Pull techniques 1. Reserve breech extraction 2. Patwardhan method (cid:127) A DATIX is required Assumed prior knowledge or interdependency [what do people need to know before they attend this session?]: (cid:127) Previous practice experience (cid:127) Previous training on the management of IFH (cid:127) Local guideline information 3 ________ _ _ _____ NHS Royal Berkshire ___________NHS Foundation Trust Resources [what is needed for this session?): (cid:127) Limbs and Things birth mannequin and enhanced caesarean module (cid:127) Computer for video to show Patwardhan method Assessment (how will we know that learning has been effective?) (cid:127) Post learning discussion with faculty and demonstration of correct techniques by attendees Increase in Datix submissions (cid:127) Differentiation (addressing ail *learners* needs)- [how will the session adapt to be inclusive for all learners?) (cid:127) Videos (cid:127) Hand on training (cid:127) Written information to take away, Printed copy of the algorithm for IFH 4 Appendix 2 Draft SOP Process for safety Action SOP (cid:127) Process for Safety Actions NHS Royal Berkshire NHS Foundation Trust Work as specified Work as agreed Work as done AtfOflLttd Action AndOmoscaM » p w d wnh owner teefotereport Wen-off OenerMet <4am*| Aetpame lorea CM*irt « Action AMi DATtX M T V Maruttr N o t f M (Automatic) M « « Miix bfonw OolceiGowmervtfOeH 1 UCG| *enft dsWfWed t M <wns«4in Ur* feMrtffwn*'! 5
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