“A decision was made by the midwife who had been with throughout her delivery to move to…”
Dated 25 Apr 2022, from the coroner for South Yorkshire West. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 20 Jun 2022. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated25 Apr 2022
- Deadline20 Jun 2022
- Published on judiciary.uk29 Apr 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Sheffield Teaching Hospitals NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 20 Jun 2022. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. A decision was made by the midwife who had been with throughout her delivery to move to an episiotomy. Instead, the midwife that came to support encouraged further position changes leading to delay in delivery and inadequate monitoring of the foetal heart rate. Whilst the decision seek support for the episiotomy is not one which I would criticise, people should always be able to ask f or help when needed, the fact that the midwife who was with was talked out of this so readily resulting in avoidable delay is concerning. 2. The decision to move from consultant to midwife led care without consultation, although not contributory to Millie-Rae's death is concerning. 3. The lack of discussion with about birthing options prior to labour and theref ore the lack of engagement with the pregnant woman is concerning. 4. I have had sight of the new documentation around 'Born in Sheffield' and I am concerned by reference to 'normal birth' on the checklist. Again, this appears as though it is encouraging expectant mothers to be influenced into a natural birth when they may prefer to explore options such as caesarean section. Language is hugely important in terms of the experience individuals have when vulnerable. 5. Evidence was given about fresh eyes on continuous heart rate monitoring but there appear to be no safeguards in place for those not on continuous heart rate monitoring.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2022-0122
- Added to Minute Book
- 8 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
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