Recurance · prevention of future deaths reports
Pre-inquest brief
Missed breech presentation due to lack of routine prenatal scanning
The earlier warning
Leo Deady · 19 Dec 2013 · Phillip Barlow, London (Inner South)
“there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 25 Jul 2018 · Aniyah Winston · Alison Mutch · Identical hazard · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Leo Deady · 19 Dec 2013
“there is a small but significant rate of breech presentation nationally and that a significant proportion of breech presentations go undiagnosed.”
Later · Aniyah Winston · 25 Jul 2018
“pre delivery scans are not routinely carried out to try and reduce the number of undetected breeches and midwives/doctors rely on external examination.”
What happened next
No web check of the stated actions has been published for this chain.