Skip to content
recurance

Arthur Trott

29 Nov 2022 · Coroner Karen Henderson · West Sussex

The coroner's concerns

  1. 1. attempted home delivery of footling breech presentation

    “The initial advice from the labour ward and the consultant midwife employed by the ambulance service was to bring the mother into hospital as an acute obstetric emergency but on arrival at the mother's home a decision was made to attempt delivery from JRCALC guidelines indicating that it may be possible for breech presentation babies to be delivered at home. Whilst this was recognised as possible in different breech (bottom first) presentations it was not advisable nor should an attempted delivery”
  2. 2. insufficiently robust JRCALC guidance on footling breech presentation

    “The JRCALC guidance on the emergency management of footling breech presentation by the emergency services is insufficiently robust in that it should be recognised as different from other breech presentations and considered an acute obstetric emergency requiring immediate transfer to the nearest hospital obstetric unit. That is, no attempts should be made to attempt a home delivery due to difficulties with the baby's head not being able to be delivered.”
  3. 3. insufficient consultant midwives in ambulance services

    “On evidence heard in court there are only two consultant midwives employed by the Ambulance services despite there being 11 Ambulance organisations within England. This leaves the majority of ambulances services having no obstetric support, guidance or ongoing teaching and training. As a matter of urgency there is a need to provide resources to employ more consultant midwives - at least one to two per service - throughout all the Ambulance organisations”

Responses

No published response was found on judiciary.uk.

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error

Arthur Trott · Recurance