Dear Ms Brown, Inquest concerning the death of Mohammed Ismail Khan. Response to Regulation 28 of the Coroners (Investigations) Regulations 2013. I am writing in response to the Regulation 28 notice issued following the conclusion of the investigation into the death of Mohammed Ismail Khan on the 4th September 2025, who sadly died on the 6th September 2022. I extend my sincere condolences to Mohammed’s family and friends. We acknowledge the serious concerns raised regarding findings from the WMAS investigation which concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk, and the importance of taking meaningful action to prevent future deaths. NHS Birmingham and Solihull (BSOL ICB) has carefully considered the issues outlined in your report and will work closely with Black Country ICB who will coordinate a single, collective response to the Regulation 28 notice on behalf of all West Midlands ICBs by 11th November 2025. The ICB takes the recommendations within the Regulation 28 report extremely seriously. We are committed to support Black Country ICB and WMAS in delivering the necessary improvements to the service and we recognise the importance of learning from this tragic event to help prevent similar incidents in the future. If we can be of any further assistance at this time, please do not hesitate to contact me.

Dear Ms Brown

Re: Mohammed Ismail Khan

Thank you for your email dated 16 September 2025 attaching your Regulation 28 Report.

On behalf of West Midlands Ambulance Service (WMAS), I am sorry that you have had to raise concerns following the Inquest of Mohammed. May I please take this opportunity to pass on my sincere condolences to the family of Mohammed. I am deeply saddened by this case.

Please see our response to your concerns.

Concern 1 , West Midlands Ambulance Service (‘WMAS’) Clinical Manager Maternity Lead - gave evidence regarding the findings of WMAS Serious Incident Investigation. She explained:

a. At 18:55 on the 06.09.22 the trust received a 999 call for Mohammed’s mother, Mrs Khan, who was 36 weeks pregnant and it was reported the baby (Mohammed) was being born feet first.

b. A category 1 disposition of “Emergency Ambulance Response for Obstetric Complications” was reached.

c. At 18:58, the 1st double crewed ambulance (DCA) resource was dispatched and arrived at 19:07, a further DCA and Operations Manager also attended.

d. The clinicians in attendance had no prior experience of breech deliveries.

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e. They advised Ms Khan to move from standing to all 4s and this progressed the delivery a little, visible parts of the baby were indicative of hypoxia, and the umbilical cord was white and non- pulsing. They followed a ‘hands off’ approach and sought advice from the regional trauma desk who advised rapid transfer to hospital and had pre-alerted Birmingham Heartlands Hospital (BHH).

f. The crew left at 19:20 and arrived at BHH at 19:24. The patient was admitted to theatre at 19:26 and following Lovsett's maneuver Mohammed was born at 19:27 with no heart rate and no respiratory effort. Although he responded to resuscitation, he had suffered profound severe hypoxic ischemic brain damage.

Response gave evidence to suggest Mohammed had been presenting as feet first (footling breech) for 7 minutes prior to the 999 call being made. When the clinicians arrived on scene, he had descended up to his waist and they immediately asked his mother to go onto all-fours to try to aid birth. This helped the birth progress to his naval, but when the birth did not progress further, a decision was made to immediately transfer Mum and Mohammed as the clinicians felt they would be unable to manage this safely on scene. Attempting to assist, would have caused a greater delay on scene.

It is noted that Mohammed was born using the Lovesett’s manoeuvre. At the time of the incident, the paramedic breech birth algortihm did not provide sufficient detail on how to perform the full manoeuvre. The guidance has since been updated to make it clear and allow paramedics to use this manoevre safely and effectively when needed.

The new guidance also includes additonal pictures, videos and step-by-step advice on what to do when birth is imminent or not imminent, how to position the mother and when and how to use certain manoeuvres if required.

Concern 2 The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted.

Response As stated during the evidence given, at the time of the incident, the national guidance was for delayed breech births to be assisted with additional manoeuvers as described on the WMAS Maternity Action Card. The Action Card was missing from the first ambulance, but a clinician from the second ambulance had a card in their pocket which was followed until the birth failed to progress past the naval. The information on the card after this point was imprecise which led to a decision being made to immediately convey Mum and Mohammed to a place of specialist maternity care which was provided at Birmingham Heartlands Hospital.

This card has now been removed from all Trust vehicles, the Regional Trauma Desk and destroyed. A Clinical Notice has also been distributed to ensure all clinicians destroy any WMAS Maternity Action Cards in their possession.

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Concern 3 Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development.

Response We firstly apologise if the evidence given has caused confusion, has stated her evidence regarding mandatory training was in relation to University training, which is where content delivery may differ, not the training West Midlands Ambulance Service provides.

Training for obstetric emergencies is provided within The Level 4, 5 and 6 Associate Ambulance Practition (AAP) Programme which is a regulated training programme for all student paramedics on the apprenticeship pathway employed by WMAS.

The Graduate Paramedic Programme is a clinical induction for all newly qualified paramedics who have been employed by WMAS but have completed their training with a University. Graduate Paramedics must complete this programme in order to be able to work operationally on an ambulance.

Within the Level 4 AAP Programme and the Graduate Paramedic Induction programme obstetric emergencies including breech birth are covered in the content summarised below:
- Overview of breech birth
- Types of breech presentation
- Risk factors
- Current JRCALC algorithms
- Management of complications
- Criteria for rapid transport
- Transport and conveyance considerations and positioning The Trust invested in 5 “Victoria” mannequins at a cost of £69,000 each at the end of 2023 making simulation more realistic. These state of the art simulators are unique in their ability to autonomously simulate childbirth and integrate seamlessly with the Trust’s Zoll Series monitor enabling real-time monitoring of the mother’s vital signs during training scenarios. Victoria offers ambulance staff the most realistic and immersive training exeriences for handling all obstetric emergencies including breech birth.

Practical sessions have also been timetabled into the AAP course and Graduate Paramedic Induction Programme, allowing learners to simulate breech births using the Victoria birthing mannequins, as well as other maternity training equipment such as birthing pelvises and training babies. These sessions were updated in 2023 following the new guidance.

A Clinical Supervision shift (CS1) is mandatory for all ambulance clinicians and during this shift planned in the year 2024/25, staff were informed to review the new JRCALC guidance on breech delivery.

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West Midlands Ambulance Service clinicians partake in yearly refresher mandatory training both face to face in a classroom and online. Prior to this PFD being issued discussions and planning had taken place to include obstetric emergencies including breech birth within next year’s 2026/27 face to face mandatory training.

In addition, planning began in August 2025 to refresh the Trust’s local priorities for the Patient Safety Incident Response Framework (PSIRF) to include Obstetric Emergencies encompassing breech births.

Concern 4 The clinicians who attended said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.

Response As presented by in her evidence, it is recognised that ambulance clinicians do not frequently attend obstetric emergencies which could lead to staff lacking in confidence to manage these cases.

The Trust has a Risk Assessment in place which is reviewed on an annual basis to identify any gaps or further learning opportunities.

The clinicians involved in this case attended supportive remedial training specifically focused on breech birth.

Concern 5 explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.

Response Following the recommendations of the Ockenden Report, in December 2022, arranged for paramedics to attend Birmingham Women’s Hospital for observation shifts. Unfortunately due to staffing shortages within midwifery, this was paused by the maternity unit.

The Trust has put multiple measures in place to provide Continual Professional Development (CPD) to our staff including well attended “Maternity Roadshows” led by in September and October 2023 where a Victoria mannequin was utilised to simulate births and obstetric emergencies supported by the Maternity Champions. In September 2023, we held a themed Maternity Month where Maternity Roadshows were held with 9 expert guest speakers. On October 9th 2024, one of the guest speakers was a Breech Specialist Midwife from Birmingham Women’s Hospital who demonstrated a live breech birth simulation using a Victoria mannequin.

Health Education England awarded the trust funds to invest in 5 “Victoria” mannequins at a cost of £69,000 each at the end of 2023 making simulation more realistic. These state of the art simulators are unique in their ability to autonomously simulate childbirth and integrate seamlessly with the Trust’s Zoll Series monitor enabling real-time monitoring of the mother’s vital signs during training scenarios. Victoria offers ambulance staff the most realistic and immersive trainin exeriences for handling all obstetric emergencies including breech birth.

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As presented in evidence, in 2023 the Trust implemented Maternity Champions to share learning opportunities and support staff who lack in confidence, there is at least one Maternity Champion on each operational hub.

The Trust published a special edition of the Clinical Times in August 2024 called “Maternity Matters” which included information on maternal assessment as well as some obstretric emergencies.

On the 3rd September 2024, the first National Pre-Hospital Maternity and Newborn Conference was held in Birmingham which was attended by our Trust midwife and 14 maternity champions highlighting the Trust’s commitment to advancing safe maternity care.

In response to the Ockenden Report, a “Maternity Action Plan” was devised to provide a summary of the Trust’s response to new local and national maternity practice. This action plan demonstrates that robust actions are consistently being taken to ensure maternity services WMAS provide are safe and robust. A number of recommendations are suggested and are ongoing, including to create maternity CPD training videos. This paper is reviewed and re-presented twice a year.

The Trust has implemented emergency “red pre-alert phones” in all 15 maternity units across the region, these phones allow our clinicians to seek immediate help if on scene with an obstretric emergency requiring immediate transportation. The use of these phones was promoted during World Patient Safety Day 2025 along with the Pre-Hospital Maternity Decision Tool.

The Trust has also proposed a local priority for April 2026-April 2027 under the Patient Safety Incident Response Framework (PSIRF) that will focus on obstetric emergencies including breech birth falling outside of the Maternity and Neonatal Safety Investigations (MNSI) criteria.

Whilst partaking in World Patient Safety Day 2025 where the theme was “Safe care of every newborn and every child” the Trust celebrated the use of the Transwarmer which is a device used to support thermoregulation, this had been recognised as an “excellent theme” demonstrating improvement within obstetric emergencies.

Concern 6 Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training
e.g. less than a third of paramedics with WMAS have completed the online course.

Response At the time of the Inquest, the e-PROMPT course was paused due to updates and changes in national guidance so our clinicians could not complete this additional training. This was not due to resourcing. The course has now been relaunched and on 16th October 2025 our Education and Training Department advertised this in our Weekly Briefing and clinicians can now complete this.

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Health Education England awarded the Trust funds to invest in 5 “Victoria” mannequins at a cost of £69,000 each towards the end of 2023 making simulation more realistic. These state of the art simulators are unique in their ability to autonomously simulate childbirth and integrate seamlessly with the Trust’s Zoll Series monitor enabling real-time monitoring of the mother’s vital signs during training scenarios. Victoria offers ambulance staff the most realistic and immersive trainin exeriences for handling all obstetric emergencies including breech birth.

West Midlands Ambulance provides regulated training that includes Breech Birth within the Associate Ambulance Practitioner Course (AAP) and training within the Graduate Paramedic Induction Programme which must be completed prior to being an operational paramedic.

Mandatory face to face refresher training for all ambulance clinicians on obstetric emergencies including breech birth will be included in the programme for 2026-2027.

Concern 7 evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk.

Response It is professional opinion, the absence of nationally mandated annual refresher training on obstetric emergencies affects the confidence and competence of clinicians in managing these emergencies. She emphasised that this represents a national issue within the profession rather than a matter specific to WMAS.

Operational staff have access to the JRCALC clinical guidelines, which provide evidence-based guidance for the management of obstetric emergencies. These guidelines are readily available and regularly updated.

When using the term mandatory training during her evidence used the term to mean training in relation to University training. recognises that mandatory training could also be interpreted to mean mandated annual refresher training outside the ambulatory sector. apologises if her use of the term was not made clear during her evidence. While there is no standalone mandatory module specifically for obstetric emergencies, relevant content is incorporated into broader clinical refresher training and continuous professional development. This ensures that staff remain competent, confident, and able to manage such cases safely and effectively.

Since this incident we have implemented a number of actions as described above but noteably:
- Face to face mandatory refresher training has been included for 2026-2027 that will include breech birth.
- Resumption of the e-PROMPT course.
- A Trust focus on learning and improvement of obstetric emergencies with a proposed PSIRF priority covering this area.
- Removal and destruction of out of date WMAS Maternity Action Card from all Trust Vehicles.

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- A Clinical Notice to all clinical staff advising them to remove the out of date WMAS Maternity Action Card from their possession and destroy it. It is hoped that the above information provides you with assurance that WMAS includes obstetric emergencies within mandatory training alongside multiple other areas to promote safe maternity care within our organisation and that patient safety is our priority.

Once again please pass on our sincere condolences to the family of Mohammed Khan. We are sorry we let Mohammed and his family down.

If you require any further information, please do not hesitate contact us.

Your sincerely,

Clinical Manager - Maternity Lead / Trust Midwife

Director of Nursing

Dear Ms Brown

MOHAMMED ISMAIL KHAN (DECEASED)

I am writing in response to the preventing future deaths report issued to our executive officer at the Association of Ambulance Chief Executives (AACE), and I respond as our Director of Operational Development and Quality Improvement on behalf of AACE.

On behalf of AACE, I would like to extend our sincere condolences to the parents and family of Mohammed Ismail Khan.

It may be helpful for us to explain that AACE is a private company owned by the English and Welsh Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, co-ordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. It is a company owned by NHS organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). AACE is not constituted to mandate or instruct ambulance services however it has national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups.

We respond by providing comments to your matters of concern relating to ambulance clinical guidelines (JRCALC) and training and education of ambulance staff. We recognise and acknowledge that breech birth is a high acuity, low occurrence presentation to ambulance staff and that ideally a woman should be in a hospital obstetric unit to have her baby.

The JRCALC guidelines are advisory and have been developed to assist paramedics make decisions about the management of the patient’s health, including treatments and to support clinical practice. The advice is intended to support the decision-making process and is not a substitute for sound clinical judgement. We recognise that the guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore, we expect that paramedics using JRCALC guidelines ensure they have the appropriate knowledge and skills to enable suitable interpretation.

The JRCALC guidelines contain guidance on the assessment and management of maternal emergencies, and we have a specific guideline for breech birth. The guideline was updated in September 2023 following extensive review by obstetricians, midwives, and paramedics. During the

review we reviewed the available published clinical evidence around breech birth management and also considered reviews and outcomes of known incidents of breech births in the prehospital environment. We found that the published clinical evidence and guidance available was mainly hospital based and written predominantly for midwives and obstetricians.

We took a consensus approach to our guidance as it needed to be written for paramedics who may have not had clinical experience of a breech birth due to its low incidence in the prehospital environment. The aim was to ensure that the guidance was as simple, clear, and easy to use as possible. As part of the process, we asked a number of paramedics to review the management of breech birth algorithm for its ease of use and whether it was clear to them if they were to use it in an emergency situation. We also built into the guidance photographic images using mannequins to help show the specific manoeuvres that we recommend to deliver the baby and in addition we included short video clips.

The guidance details when to consider moving the mother to hospital, how to position the mother and how to support delivery of the baby. It is a difficult decision in a highly stressful situation to decide to try and move the mother to hospital if she is in in the process of delivering her baby and if a visible part such as limb has been delivered but delivery of the head is delayed. We provide guidance on this and emphasise the time critical nature of a breech birth delivery and that ideally the mother should be in an hospital obstetric unit. We have received feedback through our networks that since we issued the revised guidance it is helpful and that it has been used to support the delivery of breech babies.

With regard to your matter of concern around the training and education of paramedics, AACE are not responsible for this. However, we have shared the report via our networks and specifically with the national education network for ambulance trusts (NENAS), with the national pre-hospital maternity and newborn care group and the national ambulance services medical directors’ group (NASMeD) for them to consider your matters of concern in their own organisations.

With regard to under-graduate and post-graduate paramedic training we are aware of variation in the provision of training for paramedics in maternity care and breech birth in both Universities (accredited by the HCPC) and ambulance services which for qualified paramedics is the responsibility of individual ambulance trusts. Additionally, we do not have any control over the allocation of specific funding for maternity training. We are aware that some training is delivered face-to-face to staff, often supplemented by online modules, webinars, and instructional videos. Simulation and hands on practice are widely used with training covers both theoretical and practical skills. Refresher training varies with some services offering training every 1-4 years, annually or as a part of continuous professional development.

If you have any further questions, please do not hesitate to contact us again.