Royal Berkshire Hospital
NHS / Health Body
Action Taken
The trust has now ensured that all obstetric doctors (ST1 and above Resident Doctors and Consultant Obstetricians) and all band 7 delivery suite and maternity clinical co-ordinator midwives have been trained in managing IFH which includes how to safely disimpact the fetal head vaginally and considering various manoeuvres abdominally. A training plan was drawn up by the maternity team and the obstetric governance team. This includes familiarity with local guidelines for management of IFH including escalation and knowledge of the algorithm and understanding risk factors and complications. (AI summary)
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Dear Mrs. Connor Thank you for your Regulation 28 report dated 27th October 2025 concerning the death of Louisa Walker who died on 28th June 2024. I would like to take this opportunity to express my deepest condolences to Louisa’s parents . The Royal Berkshire Foundation Trust (RBFT) is committed to learning from deaths and improving patient safety. Please find below the trust’s response in relation to the prevention of future deaths report. Matter of Concern:
1) If the trust is taking this matter very seriously and is committed to learning, I am concerned that 83% of their obstetricians have not undergone this training. For the avoidance of doubt, the training referred to is training arising out of this incident, and not standard obstetric training on this issue, provided before Louisa’s death. Impacted Fetal Head (IFH) training The Impacted Fetal Head (IFH) training referred to in the PFD was developed locally for midwives and doctors in response to this incident, as the department recognised the need for urgent training. It was deemed too long to wait for the Royal College of Obstetricians and Gynaecologists (RCOG) ‘ABC’ (Avoiding Brain Injury in Childbirth) training, which is due to be implemented early in 2026. Training in managing IFH is undertaken throughout Obstetric training, and all Consultants are deemed competent to manage this scenario by the completion of their training. Following the inquest we have now ensured that all obstetric doctors (ST1 and above Resident Doctors and Consultant Obstetricians) and all band 7 delivery suite and maternity clinical co- ordinator midwives have been trained in managing IFH which includes how to safely disimpact the fetal head vaginally and considering various manoeuvres abdominally. A training plan was drawn up by the maternity team and can be found in appendix 1. As of 24th November 2025, 100% of these groups have completed the training. The training sessions have allowed for multi-disciplinary hands-on training for those who have attended and has increased the awareness of IFH. There will also continue to be ongoing monthly drop-in sessions for hands-on training for other staff as well as doctors who may wish to practice their skills. We have an ACP (Advanced Care Practitioner) in the trust who is part of the regional team involved in training and implementing the upcoming RCOG ABC IFH training and will be responsible for training the Practical Obstetric Multi-Professional Training (PROMPT) faculty locally with a plan for IFH training to be implemented into the routine PROMPT schedule from early next year. 1
NHS Royal Berkshire NHS Foundation Trust Review of Governance processes The governance processes for oversight and management of action plans have been reviewed by the maternity team and are now integrated into the draft wider Patient Safety Incident Response Framework Plan. As detailed in Appendix 2, this revised framework ensures that all incidents, complaints, and claims are captured from various channels, aligned at Trust level, and systematically reviewed at the Maternity Governance meeting for appropriate oversight and accountability. Action plans are discussed monthly at the Maternity Risk meeting, with progress monitored via the Datix system. Escalation of issues and assurance of completed actions are tracked through Maternity Clinical Governance, Urgent Care Group Governance, and Trust-level Quality Governance Committee, with final oversight by the Board Quality Committee. I trust this has provided the required assurance in relation to the changes that have been implemented within both the speciality and Trust wide governance processes in order to improve patient safety. Please do not hesitate to contact me should you need any further information.
1) If the trust is taking this matter very seriously and is committed to learning, I am concerned that 83% of their obstetricians have not undergone this training. For the avoidance of doubt, the training referred to is training arising out of this incident, and not standard obstetric training on this issue, provided before Louisa’s death. Impacted Fetal Head (IFH) training The Impacted Fetal Head (IFH) training referred to in the PFD was developed locally for midwives and doctors in response to this incident, as the department recognised the need for urgent training. It was deemed too long to wait for the Royal College of Obstetricians and Gynaecologists (RCOG) ‘ABC’ (Avoiding Brain Injury in Childbirth) training, which is due to be implemented early in 2026. Training in managing IFH is undertaken throughout Obstetric training, and all Consultants are deemed competent to manage this scenario by the completion of their training. Following the inquest we have now ensured that all obstetric doctors (ST1 and above Resident Doctors and Consultant Obstetricians) and all band 7 delivery suite and maternity clinical co- ordinator midwives have been trained in managing IFH which includes how to safely disimpact the fetal head vaginally and considering various manoeuvres abdominally. A training plan was drawn up by the maternity team and can be found in appendix 1. As of 24th November 2025, 100% of these groups have completed the training. The training sessions have allowed for multi-disciplinary hands-on training for those who have attended and has increased the awareness of IFH. There will also continue to be ongoing monthly drop-in sessions for hands-on training for other staff as well as doctors who may wish to practice their skills. We have an ACP (Advanced Care Practitioner) in the trust who is part of the regional team involved in training and implementing the upcoming RCOG ABC IFH training and will be responsible for training the Practical Obstetric Multi-Professional Training (PROMPT) faculty locally with a plan for IFH training to be implemented into the routine PROMPT schedule from early next year. 1
NHS Royal Berkshire NHS Foundation Trust Review of Governance processes The governance processes for oversight and management of action plans have been reviewed by the maternity team and are now integrated into the draft wider Patient Safety Incident Response Framework Plan. As detailed in Appendix 2, this revised framework ensures that all incidents, complaints, and claims are captured from various channels, aligned at Trust level, and systematically reviewed at the Maternity Governance meeting for appropriate oversight and accountability. Action plans are discussed monthly at the Maternity Risk meeting, with progress monitored via the Datix system. Escalation of issues and assurance of completed actions are tracked through Maternity Clinical Governance, Urgent Care Group Governance, and Trust-level Quality Governance Committee, with final oversight by the Board Quality Committee. I trust this has provided the required assurance in relation to the changes that have been implemented within both the speciality and Trust wide governance processes in order to improve patient safety. Please do not hesitate to contact me should you need any further information.