Mohammed Khan

1. 1. delayed emergency ambulance response to obstetric complication

   “At 18:55 on the 06.09.22 the trust received a 999 call for [the deceased]'s mother, Mrs [name redacted], who was 36 weeks pregnant and it was reported the baby ([the deceased]) was being born feet first”

2. 2. non adherence to JRCALC breech birth guidelines

   “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”

3. 3. lack of mandatory obstetric emergency training for paramedics

   “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”

4. 4. lack of confidence in performing breech delivery techniques

   “The clinicians who attended Mrs [name redacted] said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised”

5. 5. low priority allocation to obstetric emergencies

   “maternity and obstetric care makes up 3 per cent of emergency ambulance responses”

6. 6. absence of mandatory obstetric emergency training

   “absence of any mandatory training on obstetric emergencies was putting lives at risk”

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