“[250-word statement addressing what circumstances of the death have led to the coroner’s…”

The coroner’s concerns

[250-word statement addressing what circumstances of the death have led to the coroner’s concern, and why the coroner thinks the person to whom the report is directed is responsible for taking action to prevent future deaths. This statement must not propose what action should be  taken, as coroners cannot make recommendations]. On 21st September 2025 the University Hospitals of Birmingham NHS Foundation Trust had a  local guidance on fetal monitoring that included a section on loss of contacting highlighting that,  amongst other things, loss of contact could be due to acute fetal bradycardia or demise and that after allowing a timeframe of 3 minutes to relocate the fetal heart rate (‘FHR’) if unable to do so,  assume potential fetal bradycardia and commence emergency procedures. The Trust had  introduced this guidance due to common themes relating to lack of oversight of potential acute  causes of loss of FHR contact during constant fetal monitoring. The 3-minute period derived  from the “3, 6, 9, 12” emergency obstetric training mnemonic for ensuring rapid escalation and  timely delivery. In Amelia’s case between 03:02 and delivery there were several periods where contact was lost  for over 3 minutes, including one of 21 minutes, without emergency escalation. The Trust  guidance was not known to 3 of the practitioners involved (a band 6 midwife, a band 7 midwife  and a specialist trainee 4), 2 of whom had only recently started working at the Trust. Evidence  was that the absence of similar guidance in NG22 hampered awareness. The evidence was that this local policy is not reflected at all other maternity units nationally. Whilst action has occurred and is ongoing to raise awareness of the Trust guidance this is not a  local issue and life is at risk if maternity practitioners are not aware of the need to escalate  promptly when the FHR remains undetected after a reasonable period of action to relocate it. It  is my belief that you are able to raise awareness. 11 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every interested person who in my opinion should   receive it. I also may send a copy of the report to any other person who I believe may find it useful or of  interest. I can confirm I have sent the report to: (please do not use individual’s names, but instead  roles/titles) 1.The parents of Amelia 2.The University Hospitals of Birmingham NHS Foundation Trust  [Text Wrapping Break] 3. The MNSI 4. The nursing and midwifery council I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026) . Any representations will be  sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional  information relating to the publication of  reports and responses. 12 SIGNATURE Emma Brown Area Coroner for Birmingham and Solihull Amelia Nasiadka – Prevention of future deaths report – 2026-0414_Published Download

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judiciary.uk, Prevention of Future Deaths reports, 2026-0414

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14 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0