Pippa Gillibrand
Evidence boundary. This page is a structured project extraction from the linked primary Prevention of Future Deaths source. It is not the report text. Do not infer cause, prevalence or product-wide performance beyond the source and the explicit qualification below.
Open the primary Judiciary source · Source register: SRC-198 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2026-0042 |
| Registered primary source | SRC-198 |
| Report date | 2026-01-27 |
| Coroner area | Cheshire |
| Clinical setting | Community home-birth and acute maternity care |
| Care transition | Home-birth fetal monitoring to transfer and hospital delivery |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Maternity and paediatric care |
| Predominant information boundary | Hybrid paper and digital record |
The workflow, browsing-context and predominant-boundary fields are retained navigation aids. They are not additional coronial findings, and a single primary value cannot express every aspect of a multi-setting or multi-mechanism report.
Care-pathway classification
This classification distinguishes where safety-relevant information or work arose, where action was expected and where the digital or information workflow failed. It is a project coding of the source, not a coronial statement. “Origin” does not mean the organisation caused the harm.
| Dimension | Project classification |
|---|---|
| Settings and pathway participants | Patient or home, Community maternity care, Ambulance, NHS 111 or urgent response, Acute maternity or neonatal care |
| Information or work-item origin | Community maternity care |
| Origin care context(s) | Community care |
| Expected action destination | Community maternity care |
| Destination care context(s) | Community care |
| Directional pathway | Community maternity care → Community maternity care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Originating service |
| Classification confidence | high |
Classification note: The failed record was created and used by community midwives at home, within a wider pathway that later involved ambulance transfer and acute maternity care.
Classification confidence applies only to this care-pathway coding. It is separate from extraction confidence, source authority and causal certainty.
Evidence status and qualification
| Field | Status |
|---|---|
| Extraction confidence | high |
| Verification status | Primary source linked; high-confidence extraction |
| Response evidence status | Response evidence noted |
| Registered response sources | SRC-245, SRC-247, SRC-248 |
| Non-exclusive mechanism codes | GOV, VIS, HF, RES |
Qualification recorded in the dataset: The coroner found delays in identifying fetal-heart concerns contributed to delayed delivery and death; connectivity was one of several staffing, experience and monitoring factors. Warrington and Halton Hospitals NHS Foundation Trust was copied as an interested person, not named as a Regulation 28 recipient. NHS England’s attached 2025-11-26 homebirth circular is registered as SRC-246 but is not a response to this PFD.
“Response evidence noted” means only that the row qualification refers to response/respondent evidence or records a recipient's post-report position. The linked IDs enumerate the official response attachments registered for this row; they do not imply that every response supports every part of the qualification, and they do not establish implementation. “Not assessed” makes no claim about whether a response exists.
Structured project extraction
These fields are analytical summaries, not quotations.
Project summary of the coroner's concern
National home-birth guidance did not specify a backup if electronic systems fail, including whether paper notes should be routinely available
Requested action
NHS England, NICE and the Secretary of State for Health and Social Care to address national home-birth guidance, including electronic-system fallback
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Laptop-based electronic maternity record and partogram |
| Digital function | Fetal-heart recording and trend display |
| Failure mode | Connectivity prevented use of the electronic partogram and no paper record was available after the Trust moved to electronic recording |
| Human-factors issue | Midwives split attention between care, equipment setup, staffing discussions and attempts to connect laptops |
| Workflow issue | The digital-only workflow had no usable fallback for five-minute observations and trend review at home |
| Information issue | Fetal-heart observations were not plotted in the trend representation intended to support deterioration recognition |
Downstream Defence trace
No canonical candidate Defence requirement currently cites this report. This does not imply that the mechanism is irrelevant; any mapping must be added and qualified in the controlled requirements register.
The included-case dataset preserves early legacy_military_relevance and legacy_derived_requirement fields for audit history. They are not published here as requirements and must not override the canonical REQ register. New report rows do not need to populate them.