Aylina Akhmadova

Dear Ms Bourke, Subject: Royal College of Midwives (RCM) response to Regulation 28: Report to Prevent Future Deaths Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Aylina Akhmadova. The Royal College of Midwives (RCM) would like to begin by expressing our sincere condolences to the family and all those affected by the death of Aylina. The RCM is a professional association and trade union and does not hold statutory or operational responsibility for the delivery of maternity services. However, we play a key role in representing the professional voice of midwives, influencing policy, representing midwives and maternity support workers both individually and collectively in the workplace and working collaboratively with practice partners to advocate for safe, effective and high-quality maternity care. The response to this report is in the context of our responsibilities as a stakeholder within maternity services. We have carefully considered the matters of concern in your report. While the RCM does not have authority to implement changes at service-level, we have identified actions under each point that are within our remit and/or sphere of influence:
1. Primary care professionals such as GP’s, health visitors and midwives spend the most one-on-one time with families. They will be aware which patients and/or carers need assistance from interpreters for medical appointments. In primary care, professionals often give safety netting advice regarding the circumstances in which a person may need to call paramedics. For safety

[Page 2] netting advice to be effective, patients and carers also need to know that a 999 call should be made by someone who is with the patient and that interpreters are available to help the ambulance service triage the call.
• At first antenatal booking, midwives provide guidance to women about how to contact a midwife or ambulance, however the RCM previously raised concerns that there is inconsistency in interpreter support.
• The RCM position statement ‘Decolonising practice in midwifery’ identifies communication as central to addressing the disparities in outcomes faced by women from ethic minority backgrounds. Though there is no detail in your report around the ethnicity of Aylina and her family, it is known that her parents required interpreting services for medical appointments. The Maternal, Newborn and Infant Clinical Outcome Review Programme in their 2025 report Mothers and Babies: Reducing Risk through Audits and Confidential Enquires across the UK (MBRRACE-UK) identified that women who did not speak English, those who belonged to ethnic minority groups and those born outside the UK are overrepresented in poor outcomes.
• This is exactly the kind of risk the RCM Maternity Disadvantage Tool (MatDAT) is designed to surface early. MatDAT that provides midwives with a standardised way to assess social complexity at booking, including communication and interpreter need, so that risk is identified and support from other agencies is triggered before it becomes a safety issue.
• Adequate staffing is essential for midwives to ensure the time to build the trusted relationship through which this kind of information is disclosed. This is the basis of the RCM campaign, Safe Staffing=Safe Care, and is echoed in NHS England’s Core20PLUS5 programme, which identifies maternity as a priority area for reducing health inequalities.
2. Using informal interpreters such as family and friends for primary care appointments can be a pragmatic solution when professional interpreters are not available. However, the practice carries a significant degree of risk as the informal interpreter may not convey information reliably. This can be mitigated in part if the healthcare professional is with the patient and able to form their own view of the patient’s status based on the observations that can be made.
• The NHS Constitution requires the NHS to promote equality in the services it provides, with a greater focus being placed on groups where the improvements in health lag behind the rest of the population. Integrated Care Boards (ICBs) and trusts are best placed to identify and meet local needs therefore they hold responsibility for commissioning interpreting services. In-person, trained interpreters remain best practice. Where communication happens through family members or informal interpreters, Midwives, working in accordance with the Nursing and Midwifery Council (NMC) Code mitigate risk through direct observation, non-verbal

[Page 3] assessment, and checking the woman’s own understanding and responses, rather than relying solely on the informal interpreter’s account.
• Staffing pressure is a direct driver of reliance on informal interpreters. When Midwives don’t have time for face-to-face contact, there is less opportunity to notice communication difficultly in the first place, or to insist on a professional interpreter rather than defaulting to whoever is available. The RCM has called upon the government to invest in maternity services so Midwives can work in ways that allow for this in person contact and a more holistic assessment of a woman’s wellbeing.
• Midwifery continuity of carer (MCOC) offers a relationship-based model in which women receive care from a known midwife, supported by a small team, throughout their maternity journey. This can be particularly valuable for women experiencing vulnerability, disadvantage or language barriers, helping to build trust, improve communication and support women to engage with and navigate maternity care. The evidence demonstrates a range of positive outcomes for women and babies, however appropriate staffing is essential to ensure the success of such models of care.
• Ethnicity isn’t specified for Aylina’s parents, but the principles in RCM’s ‘Caring for Vulnerable Migrant Women Pocket Guide’ applies regardless of migrant status: removing barriers to care, and ensuring women are provided with contact numbers – especially in the cases of emergencies. Where relevant, this guide could support the staff caring for families in similar circumstance. . Point 3 does not relate to the role of the RCM and therefore we feel unable to comment further. Thank you again for raising these matters with the RCM. We trust this response addresses the matters raised in your report. Please let us know if any further information or clarification is required. CEO, General Secretary & Chief Midwife The Royal College of Midwives

Dear Sarah Bourke, Re: Institute of Health Visiting’s response to Regulation 28 Report to Prevent Future Deaths: Inquest into the death of Aylina Akhmadova aged 17 days. The Institute of Health Visiting (iHV) welcomes the opportunity to respond to the Regulation 28 Report to Prevent Future Deaths issued following the inquest into the death of Aylina Akhmadova. We fully recognise the profound tragedy of this young baby’s death and express our sincere condolences to the family and acknowledge the seriousness of the concerns raised. The Institute of Health Visiting is a professional body, charity and centre of excellence supporting health visiting practice across the UK. While we do not commission or provide statutory services, we work nationally to promote evidence-based policy and practice, workforce development, quality improvement and safeguarding practice. We have carefully considered the concerns identified by the Coroner and set out below our response, including actions already undertaken and further measures planned to raise awareness of the concerns raised and support the prevention of similar deaths in the future. Concern 1: Primary care professionals such as GPs, health visitors and midwives spend the most one- to-one time with families. They will be aware which patients and/or carers need assistance from interpreters for medical appointments. In primary care, professionals often give safety netting advice regarding the circumstances in which a person may need to call paramedics. For safety netting advice to be effective, patients and carers also need to know that a 999 call should be made by someone who is with the patient and that interpreters are available to help the ambulance service triage the call. iHV Response: The Institute of Health Visiting (iHV) recognises and shares the Coroner's concern regarding the accessibility and effectiveness of safety-netting advice provided to families who require interpreter support. Health visitors are often among the professionals who have the most frequent contact with parents and carers during pregnancy and the early years of a child's life – with a remit to proactively and systematically reach every family at 5 universal mandated contacts during the period from pregnancy to five years, and to provide additional targeted support for specific needs where these are identified. Through these contacts, practitioners are well placed to identify families with limited English proficiency and to support their access to healthcare services. Effective

[Page 2] communication is fundamental to ensuring that parents understand both the signs and symptoms that should prompt urgent help-seeking and the mechanisms by which that help can be accessed. The iHV agrees that for safety-netting advice to be effective, families must not only understand when emergency assistance should be sought but also have confidence in how to access emergency services, including awareness that interpreter services are available to support communication during a 999 call when required. The iHV has consistently highlighted the importance of equitable access to services and culturally competent care for all families, including those who face language and communication barriers. We recognise that this issue is particularly important for vulnerable infants and children, where delays in seeking emergency care may have serious consequences. The iHV also recognises the challenges posed by national health visiting workforce shortages. Sustained workforce pressures can reduce the time available during contacts for practitioners to undertake comprehensive assessments, explore families' understanding of health information, identify communication needs and reinforce key safety-netting messages at additional targeted contacts where these might be warranted. The iHV has repeatedly called for investment in the health visiting workforce to ensure that practitioners have sufficient capacity to provide personalised support to families with additional communication needs and to address health inequalities effectively. Concern 2: Using informal interpreters such as family and friends for primary care appointments can be a pragmatic solution when professional interpreters are not available. However, the practice carries a significant degree of risk as the informal interpreter may not convey information reliably. This can be mitigated in part if the healthcare professional is with the patient and able to form their own view of the patient’s status based on the observations that can be made. iHV Response: The Institute of Health Visiting (iHV) recognises the Coroner's concern regarding the risks associated with the use of informal interpreters, including family members or friends, during healthcare encounters. The iHV supports the principle that wherever possible, professional interpreting services should be used when providing healthcare to individuals and families who are not able to communicate effectively in English. Accurate communication is fundamental to safe clinical assessment, effective decision-making, safeguarding, informed consent and the provision of appropriate advice to parents and carers. The use of informal interpreters may create significant risks, including the potential for information to be omitted, misunderstood, modified or influenced by the interpreter's own beliefs, understanding or relationship with the parent/carer. Such risks may be particularly significant when discussing a child's health, symptoms of deterioration, or safety-netting advice regarding when and how to seek urgent medical assistance. Direct observation of a baby or child, by a healthcare professional, forms an important component of any assessment. Where communication is mediated through an informal interpreter, there is an increased risk that the healthcare professional may not receive a complete or accurate account of symptoms, concerns or changes in condition. This may affect clinical decision-making and, in some circumstances, delay escalation of care. Health visitors have a particularly important role in identifying communication needs during routine contacts and in supporting families to access healthcare services appropriately. Building trusting

[Page 3] relationships with families enables health visitors to better understand barriers to accessing care, including language barriers, health literacy and confidence in navigating healthcare systems. In addition, longstanding health visiting workforce shortages need to be taken into consideration (with a loss of around 45% of the health visitor workforce in England since 2015); this has significantly reduced opportunities for practitioners to spend the time required to undertake comprehensive assessments, explore parental understanding, identify communication barriers, and reinforce key health and safety messages. The iHV has consistently highlighted the need for sufficient workforce capacity to ensure that families requiring additional support receive personalised, equitable and safe care. Concern 3: The use of informal interpreters in primary care settings can lead to patients and carers wrongly assuming that emergency assistance can only be accessed by someone who is able to speak English on their behalf. Where an informal interpreter is not with the patient, there is a substantial risk that they will not be able to give sufficiently accurate and/or up to date information to enable the Ambulance Service to reliably triage a call. iHV Response: The Institute of Health Visiting (iHV) acknowledges the Coroner's concern regarding the risk that families who routinely rely on informal interpreters may incorrectly believe that emergency healthcare can only be accessed when an English-speaking family member, friend or advocate is available to support communication. As outlined in our response to Concern 2, the iHV recognises the risks associated with reliance on informal interpretation and the importance of professional language support wherever possible. This case highlights that individuals may delay or avoid seeking urgent medical assistance because they lack confidence in their ability to communicate directly with emergency services, or are not aware that interpretation support is available from these services. The iHV agrees that this represents an important patient safety issue. As covered in our response to concerns 1 and 2, when adequately resourced, health visitors are often well-placed to identify families who may experience barriers related to language, health literacy or unfamiliarity with healthcare systems. Through their ongoing relationships with families, health visitors can play an important role in supporting parents' understanding of how and when to seek urgent care, including the availability of interpreters, whilst reinforcing key safety-netting advice appropriate to the child's needs. Actions Already Undertaken - the iHV has already undertaken a range of activities that support the issues identified within this Prevention of Future Deaths Report:
• Delivered education and professional development opportunities on culturally competent and inclusive practice, reducing health inequalities and supporting families with diverse communication needs.
• Continually advocated for increased health visiting workforce capacity to enable health visitors to provide safe, effective and person-centred care.
• Promoted the use of professional interpreters where language barriers may affect assessment, communication, safeguarding or parental understanding.
• Worked in partnership with NHS Healthier Together to develop a range of web-based parent- facing resources on the management of childhood illnesses, including information on “when to worry and where to seek help”. These resources include clear Red, Amber, Green symptom guides designed to support parents and carers in recognising signs of deterioration and accessing appropriate services. The resources can be instantly translated into 39

[Page 4] commonly spoken languages and are signposted through the iHV website and routinely promoted through the Institute's work on childhood illness prevention and management. Further Actions and Commitments - The iHV considers that the issues identified by the Coroner have relevance across health visiting services nationally. Ensuring that families can understand and act on safety-netting advice, regardless of language spoken, is an important component of patient safety, safeguarding and reducing health inequalities. The iHV will therefore seek to disseminate the learning from this report widely to support improvements in practice and awareness across the health visiting profession, through the following actions:
1. Disseminate Learning from this Prevention of Future Deaths Report: Once the report is in the public domain, the iHV will disseminate learning arising from this report to its professional networks through its monthly newsletter, to raise awareness of:
• The impact of language barriers on patient safety and health outcomes.
• Good practice in the use of professional interpretation services.
• Potential barriers to accessing urgent and emergency care for families with limited English proficiency.
• The importance of effective safety-netting and health literacy - supporting parents' understanding of when and how to access urgent and emergency healthcare services and raising awareness of the availability of language support services for those who need them.
• Timescale: Once the report is in the public domain, we will include a feature in the next iHV monthly newsletter.
2. Support Professional Development: The iHV will continue to promote learning and professional development opportunities that support health visitors to:
• Recognise and address health inequalities.
• Assess and respond to communication barriers.
• Deliver effective and culturally competent advice.
• Timescale: We have training on ‘Promoting Care Across Cultures’ – with dates for 2026/27 available.
3. Review Professional Resources and Guidance: The iHV will review relevant educational materials, practice resources and professional guidance to ensure that they appropriately reflect:
• The importance of identifying and responding to language and communication needs.
• The risks associated with reliance on informal interpreters for clinical communication.
• The importance of ensuring families understand when and how to seek urgent and emergency care, raising awareness of the availability of language support services.
• Timescale: We are in the process of updating our resources to a digital format. During this process, the content on the points noted above will be strengthened in relevant resources where this is needed (this process will continue throughout 2026/27).
4. National Advocacy: The iHV will continue its national advocacy work to promote equitable access to healthcare services for all children and families, including those who experience language and communication barriers. The iHV remains concerned that longstanding health visiting

[Page 5] workforce shortages continue to affect the capacity of services to provide the level of personalised support that some families require. Health visitors play a critical role in identifying communication needs, building trusting relationships with families, improving health literacy, supporting navigation of healthcare systems, and reinforcing safety-netting messages. These activities require sufficient time, continuity and professional capacity. The iHV will therefore continue to advocate for sustained investment in the health visiting workforce to ensure practitioners are able to deliver safe, effective and equitable care, particularly for families experiencing additional vulnerabilities or communication barriers Monitoring and Governance Progress against the actions outlined in this response will be monitored through the Institute's executive leadership arrangements. The Institute of Health Visiting is committed to supporting improvements that strengthen child health, safeguarding and health visiting practice. We thank HM Coroner for highlighting these important issues and will continue to work with partners across the system to reduce the risk of similar tragedies occurring in the future.

Dear Ms Bourke Regulation 28 Report to Prevent Future Deaths - regarding the death of Miss Aylina Akhmadova Thank you for asking us to comment on the matters of concern following the sad death of Miss Aylina Akhmadova, who died on the 3rd of October 2025. Our sincere condolences go to her family given the difficult circumstances and the ongoing questions on how this could have been prevented. We will address the issues raised as requested in the hope that the response can help answer the concerns of the Coroner and Aylina’s loved ones. To give context to the family, The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medical practice by supporting members, setting standards, providing education and training, promoting research, advocating and representing the College and its 56,000 members. The central issues you have identified relate to the complexities involved in direct communication between Ambulance services and those present with Aylina at the time of need. The death occurred at a point before Aylina had contact with a GP, which illustrates the limitations of where the RCGP can influence the prevention of future deaths in similar circumstances. Opportunities to communicate to patients the matters of concern would be during pregnancy, antenatal contact and in the early days after Aylina’s birth, through the Hospital teams, Community Midwives and Health Visitor services who come into contact with families in the first days of life. The processes of the organisations representing such colleagues are beyond the remit of the RCGP, and these organisations would be best placed to respond to the concerns you have expressed, specifically that 999 calls should be made by a person who is with the patient, and that telephone interpreter services are available at the time of the encounter, as they often are within General Practice consultations. These principles can be highlighted ahead of the birth of a child in any clinical contact where formal or informal interpretation is recognised as being required. GP Records can document the necessity for professional interpreters, the languages spoken, with alerts for all staff dealing with patient queries on what organisational arrangements are needed. Arrangements could be translation in-person or via telephone, whether there is a preferred gender of the person translating, and planning extra time for consulting via the professional interpreter. These considerations are made clear in the RCGP Safeguarding Toolkit Royal College of General Practitioners 30 Euston Square, London, NW1 2FB Tel: 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk Registered Charity Number 223106 | Patron: His Majesty King Charles III

[Page 2] The Personal Child Heath Record, (also known as the ‘Red Book’), given to parents and carers for each child after birth, has extensive written information and health advice, including information to reduce the risk of Sudden Infant Death Syndrome (SIDS). Content is overseen by a multidisciplinary group hosted by the Royal College of Paediatrics and Child Health, (RCPCH). Even with the best advice that organisations can give ahead of emergencies, the direct observations of an English-speaking caller may not be available in such a short timescale in the scenario as described in Aylina’s case. Those calling ambulance services were doing what they felt was best in a distressing and pressured situation. Our GP members and their teams have the opportunity to highlight the actions to take in emergencies opportunistically in appointments for symptoms arising, as well as in routine care where families are invited into surgery for the 6-8 week Postnatal Review, with further scheduled opportunities with early vaccinations at 8, 12 and 16 weeks of age. At these encounters, specific safety netting advice can be given on clinical signs and symptoms that should raise parental concern, alongside the appropriate actions to take. They can be highlighted in written form within the Personal Child Health Record/’Red Book’ described above. Once again, our condolences go to Aylina’s family. I hope the comments provide a full picture of where the RCGP can seek to influence the prevention of future deaths within training and continuing professional development.