Finley May

Dear Sir,

Re: Finley Austin May – deceased

Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Finley Austin May dated 27 July 2023.

The loss of a baby is a devastating tragedy for parents, the wider family, and healthcare professionals involved. We would like to begin by extending our deepest and heartfelt condolences to Finley’s family for their deep loss.

This response has been developed following input from members of the RCOG Patient Safety Committee and Senior Officers of the College.

We recognise and respect the narrative conclusion from the inquest that Finley Austin May died as a result of a spinal cord injury caused by the use of Kielland’s forceps during delivery with malposition and prolonged labour.

We also recognise the matters of concern, in particular 4 and 5:

(4) Continued use of Kielland’s forceps may be the most appropriate way to manage this obstetric problem but there should be increased awareness of complications associated with its use and guidance issued about the minimum number of cases per annum needed to maintain skill levels coupled with guidance for training.

The O&G training curricula follow the GMC’s ‘Excellence by Design’ principles and have been mapped to the Generic Professional Capabilities. The curricula are competency based, rather than ‘number’s’ based, as such the College does not recommend a minimum number of cases per annum.

Trainees attaining Certificate of Completion of Training (CCT) will be skilled in managing the labour ward independently and managing the acute gynaecological on-call service. They will have expertise in practical procedures related to the clinical care of women and will be expert communicators with strong interpersonal skills, strong emotional intelligence and adept at the management of sensitive situations.

These areas ensure that doctors in training and beyond CCT can provide safe care whilst working in a range of challenging and diverse work environments, balancing acute and non-emergency service provision. The College’s programme of assessment encompasses the integrated framework of exams, assessments in the workplace and judgements made about a learner during their approved programme of training. The emphasis is on the importance of professional judgment in making sure learners have met the learning outcomes and expected levels of performance set out in the approved curricula. It also focuses on the learner as a reflective practitioner with emphasis on acting within one’s own expertise to seek support in less familiar circumstances. Assessors will make accountable, professional judgements on whether progress has been made to support decisions on progression and satisfactory completion of training.

As stated above, with regards to training, The College takes a competency versus number per year approach to continuous professional development requirements. The College supports the GMC’s Good Medical Practice guideline (points 7-10) which state that for doctors (supported by the organisations employing them):

7. You must be competent in all aspects of your work, including management, research and teaching.

8. You must keep your professional knowledge and skills up to date.

9. You must regularly take part in activities that maintain and develop your competence and performance.

10. You should be willing to find and take part in structured support opportunities offered by your employer or contracting body (for example, mentoring). You should do this when you join an organisation and whenever your role changes significantly throughout your career.

For consultant practitioners and specialists these would be assessed at annual appraisal. For doctors in training they would be assessed annually during their training assessment by the Deanery. In both instances any serious incidents need to be documented to enable review against the GMC Good Medical Practice guidance and the RCOG training matrix. The RCOG training matrix presents a progression from supervised practice to independence, as doctors in training accumulate technical skills and experience.

To support our membership in being compliant with the regulators and fulfil these requirements the College hosts a range of training opportunities including an annual training course RCOG Operative Birth Simulation Training (ROBuST). The aim of ROBuST is to provide hands-on practice in all methods of operative vaginal birth (both non-rotational and rotational) to facilitate the achievement of the OSATS (objective structured assessment of technical skills) competencies on the RCOG Training matrix. These promote an evidence base to demonstrate, develop and maintain safe clinical practice and the means to record and validate experience.

(5) If NHS trusts have abandoned the use of Kielland’s forceps, clear guidance should exist about alternative methods of managing malrotation and asynclitism.

Kielland’s forceps are currently recognised as an option to assist rotational vaginal birth in our current guidance on Assisted Vaginal Birth. The risk of cervical spine injury using Kielland’s is extremely low, but

any such serious injury is taken very seriously by the RCOG. We added a safety statement in relation to use of Kielland’s forceps to our guidance on the webpage in June 2023, which states the following:

Following several recent adverse incidents, the College wishes to remind clinicians of their key obligations to promote the safe use of Kielland's rotational forceps. Assisted vaginal birth promotes benefits to both mother and the baby when used appropriately and safely. We have no doubt that clinicians use Kielland’s forceps with a high degree of caution, and respect the skill and expertise required to facilitate a safe birth. Misuse or incorrect application of Kielland’s forceps can, however, result in serious complications for both mother and baby.

Rotational births using Kielland’s forceps should only be performed by experienced operators or under the direct supervision of an experienced operator. The operator is required to define fetal head position and identify the position of the occiput correctly, in order to safely undertake a rotational birth. In this regard, an ultrasound assessment of the fetal head position prior to application of forceps is more reliable than clinical examination and is advisable.

While ultrasound scan is not directly mandated prior to all assisted births, it should be noted that recent concerns arose following inaccurate assessment of the fetal head position by clinicians prior to starting the procedure. Procedure should also be discontinued where rotation is not easily achieved with gentle pressure, after confirming correct application.

RCOG Green-top Guideline No. 26 on Assisted Vaginal Birth, published in 2020, provides the evidence-based recommendations to support practitioners around use of instruments for assisted vaginal births, and promotes support for the availability of intrapartum ultrasonography for clinicians in their daily practice.

This area of enquiry is active with nationally funded research ongoing (ROTATE Project

be updated once this project has concluded.

The RCOG is committed to improving the standard of care provided for women by working collaboratively with all stakeholders, including Coroners.