Mabel Williams
PFD Report
All Responded
Ref: 2025-0457
All 1 response received
· Deadline: 3 Nov 2025
Coroner's Concerns (AI summary)
The RCOG information leaflet on birth options after a previous caesarean section fails to mention that uterine rupture can be fatal for mother or baby, risking uninformed patient choices.
View full coroner's concerns
When was advised about VBAC she was referred to internal guidance from the hospital and to the RCOG’s information leaflet “Birth options after previous caesarean section” (published in July 2016). I reviewed the information leaflet and it does not contain any indication that uterine rupture could potentially prove fatal for mother and / or baby. My concern is that prospective parents may rely on this information leaflet to assist them in making informed choices about their birth options, and that if the risk is not identified then other patients like might pursue VBAC in circumstances where – if they had understood the risk better – they would have chosen otherwise.
Responses
Action Planned
The RCOG patient information leaflet, "Birth options after previous caesarean section," has been reviewed and updated to include information about the potential fatal consequences of uterine rupture for both mother and baby and is due for publication in the very near future. (AI summary)
The RCOG patient information leaflet, "Birth options after previous caesarean section," has been reviewed and updated to include information about the potential fatal consequences of uterine rupture for both mother and baby and is due for publication in the very near future. (AI summary)
View full response
Dear Mr Sowersby
Re: Baby Mabel Olivia Williams
Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Mabel on 8 September 2025.
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 Mabel’s family for their profound loss.
This response has been developed following input from members of the Royal College of Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the College.
We recognise and respect the narrative conclusion from the inquest. The medical cause of Mabel’s death was:
1a) Severe hypoxic ischaemic encephalopathy, 1b) Undiagnosed uterine rupture.
We also recognise the matters of concern as outlined in your letter as follows, When Becky (Mabel’s mother) was advised about VBAC she was referred to internal guidance from the hospital and to the RCOG’s information leaflet “Birth options after previous caesarean section” (published in July 2016). I reviewed the information leaflet and it does not contain any indication that uterine rupture could potentially prove fatal for mother and / or baby. My concern is that prospective parents may rely on this information leaflet to assist them in making informed choices about their birth options, and that if the risk is not identified then other patients like Becky might pursue VBAC in circumstances where – if they had understood the risk better – they would have chosen otherwise.
The purpose of RCOG patient information leaflet is to convey essential information in an accessible format. It aims to support the individualised discussion between the clinician and the woman and their partner and/or other friends and family and is not intended to be a stand-alone resource.
All our patient information leaflets are produced in collaboration with service users and clinicians to try to ensure that they convey information that is accurate, relevant, clear and succinct. The depth of information is agreed after very careful consideration, and with input from service users and clinicians, and highlights that additional conversations with clinicians are needed to help personalise the risks for an individual.
In response to your concerns, this patient information leaflet is based on the RCOG Green-top Guideline No 45 Birth After Previous Caesarean Birth1 (October 2015). The Green-top Guideline states that uterine rupture is a rare but serious complication associated with maternal and perinatal morbidity and mortality:
Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous women in labour.
Women should be informed of the two-to-three-fold increased risk of uterine rupture and around 1.5- fold increased risk of caesarean birth in induced and/or augmented labour compared with spontaneous VBAC labour.
Approximately 0.5% risk of uterine scar rupture. If occurs, associated with maternal morbidity and fetal morbidity/mortality.
The guideline stresses the importance of early diagnosis, expeditious laparotomy, and neonatal resuscitation to reduce morbidity and mortality related to uterine rupture.
The guideline also recommends that decisions for induction and augmentation of labour in such situations should be made in consultation with senior obstetric input and after informed discussion with the woman, in recognition of the increased risks. This being an individualised discussion would be outside of the scope of a standard patient information leaflet.
The patient information leaflet Birth after Previous Caesarean2 , while not using the precise term ‘fatal’ in relation to uterine rupture nonetheless states the risks and that stillbirth can be a serious consequence of VBAC.
“Serious risk to your baby such as brain injury or stillbirth is higher than for a planned caesarean section.”
“The scar on your uterus may separate and/or tear (rupture). This can occur in 1 in 200 women. This risk increases by 2 to 3 times if your labour is induced. If there are warning signs of these complications, your baby will be delivered by emergency caesarean section. Serious consequences for you and your baby are rare”.
This RCOG leaflet has been reviewed and updated recently and is due for publication in the very near future.
Counselling for VBAC is never a one-off event. Women should be counselled antenatally, with information revisited in labour because the risk profile is dynamic, particularly where induction or augmentation of labour is being considered. It is the clinical team’s responsibility to ensure that women understand not only the numerical risks but also the potential consequences for mother and baby.
It is also important to note that, under the Core Competency Framework developed by the Maternity Transformation Programme3 and national partners, all maternity units are required to standardise training to enhance safety and consistency in care. Module 3 specifically addresses medical emergencies and multi-professional training, with a requirement that 90% of relevant staff attend annual in-house MDT training (PROMPT) covering at least four maternity emergencies over a three-year period, including uterine rupture, with priorities tailored to local needs. This framework reinforces that the unit has a responsibility to ensure that all staff, including those managing labour, are trained to recognise and respond promptly to emergencies such as uterine rupture. Responsibility therefore extends beyond the individual clinician to the unit’s broader duty to maintain competency and preparedness through mandated training.
Thank you for bringing this to our attention. I hope this is a helpful response to this matter.
Re: Baby Mabel Olivia Williams
Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Mabel on 8 September 2025.
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 Mabel’s family for their profound loss.
This response has been developed following input from members of the Royal College of Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the College.
We recognise and respect the narrative conclusion from the inquest. The medical cause of Mabel’s death was:
1a) Severe hypoxic ischaemic encephalopathy, 1b) Undiagnosed uterine rupture.
We also recognise the matters of concern as outlined in your letter as follows, When Becky (Mabel’s mother) was advised about VBAC she was referred to internal guidance from the hospital and to the RCOG’s information leaflet “Birth options after previous caesarean section” (published in July 2016). I reviewed the information leaflet and it does not contain any indication that uterine rupture could potentially prove fatal for mother and / or baby. My concern is that prospective parents may rely on this information leaflet to assist them in making informed choices about their birth options, and that if the risk is not identified then other patients like Becky might pursue VBAC in circumstances where – if they had understood the risk better – they would have chosen otherwise.
The purpose of RCOG patient information leaflet is to convey essential information in an accessible format. It aims to support the individualised discussion between the clinician and the woman and their partner and/or other friends and family and is not intended to be a stand-alone resource.
All our patient information leaflets are produced in collaboration with service users and clinicians to try to ensure that they convey information that is accurate, relevant, clear and succinct. The depth of information is agreed after very careful consideration, and with input from service users and clinicians, and highlights that additional conversations with clinicians are needed to help personalise the risks for an individual.
In response to your concerns, this patient information leaflet is based on the RCOG Green-top Guideline No 45 Birth After Previous Caesarean Birth1 (October 2015). The Green-top Guideline states that uterine rupture is a rare but serious complication associated with maternal and perinatal morbidity and mortality:
Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous women in labour.
Women should be informed of the two-to-three-fold increased risk of uterine rupture and around 1.5- fold increased risk of caesarean birth in induced and/or augmented labour compared with spontaneous VBAC labour.
Approximately 0.5% risk of uterine scar rupture. If occurs, associated with maternal morbidity and fetal morbidity/mortality.
The guideline stresses the importance of early diagnosis, expeditious laparotomy, and neonatal resuscitation to reduce morbidity and mortality related to uterine rupture.
The guideline also recommends that decisions for induction and augmentation of labour in such situations should be made in consultation with senior obstetric input and after informed discussion with the woman, in recognition of the increased risks. This being an individualised discussion would be outside of the scope of a standard patient information leaflet.
The patient information leaflet Birth after Previous Caesarean2 , while not using the precise term ‘fatal’ in relation to uterine rupture nonetheless states the risks and that stillbirth can be a serious consequence of VBAC.
“Serious risk to your baby such as brain injury or stillbirth is higher than for a planned caesarean section.”
“The scar on your uterus may separate and/or tear (rupture). This can occur in 1 in 200 women. This risk increases by 2 to 3 times if your labour is induced. If there are warning signs of these complications, your baby will be delivered by emergency caesarean section. Serious consequences for you and your baby are rare”.
This RCOG leaflet has been reviewed and updated recently and is due for publication in the very near future.
Counselling for VBAC is never a one-off event. Women should be counselled antenatally, with information revisited in labour because the risk profile is dynamic, particularly where induction or augmentation of labour is being considered. It is the clinical team’s responsibility to ensure that women understand not only the numerical risks but also the potential consequences for mother and baby.
It is also important to note that, under the Core Competency Framework developed by the Maternity Transformation Programme3 and national partners, all maternity units are required to standardise training to enhance safety and consistency in care. Module 3 specifically addresses medical emergencies and multi-professional training, with a requirement that 90% of relevant staff attend annual in-house MDT training (PROMPT) covering at least four maternity emergencies over a three-year period, including uterine rupture, with priorities tailored to local needs. This framework reinforces that the unit has a responsibility to ensure that all staff, including those managing labour, are trained to recognise and respond promptly to emergencies such as uterine rupture. Responsibility therefore extends beyond the individual clinician to the unit’s broader duty to maintain competency and preparedness through mandated training.
Thank you for bringing this to our attention. I hope this is a helpful response to this matter.
Part of a Series
2 separate reports were issued from this inquest, each sent to different organisations.
-
2025-0458
Sent to: Chief Executive, Great Western Hospitals, NHS Trust Marlborough Road, Swindon, SN3 6BBAll responded
This report (2025-0457) is shown above.
Sent To
Response Status
Linked responses
1 of 1
56-Day Deadline
3 Nov 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 19 October 2023 I commenced an investigation into the death of Mabel Olivia Williams, who died when she was 6 days old. The investigation concluded at the end of the inquest on 15 August 2025. The medical cause of Mabel’s death was 1a) Severe hypoxic ischaemic encephalopathy, 1b) Undiagnosed uterine rupture. Mabel’s mother, had previously given birth vaginally and later by caesarean section. During the period before Mabel’s birth preference was for vaginal birth, but she was particularly anxious about pregnancy and birth, fearful that she might lose Mabel, and keen to pursue the safest option she could for her unborn daughter. was warned antenatally that if she trialed vaginal birth after caesarean section (VBAC) she might experience “uterine rupture” or “uterine scar rupture”, but at no point was she told what that phrase actually meant, how severe rupture could be, or that it could carry with it the risk of death for her unborn child (or indeed for her). On 4 September 2023 chose to undergo a trial of VBAC at the Great Western Hospital in Swindon. During VBAC she was induced, and in due course she was started on synthetic oxytocin without being counselled that this further increased the risk of uterine rupture. A number of further significant errors were made in care and in due course she experienced progressive uterine rupture which caused increasing distress and ultimately a fatal hypoxic episode for Mabel, who was born alive but died 6 days later. My conclusion at the end of the inquest was that “Mabel died because numerous indicators of her own distress, and of the increasing severity of her mother’s clinical condition, went unrecognised by the midwifery staff involved in her care or were not conveyed to the clinical team in time to expedite her birth safely. Neglect contributed to Mabel’s tragic death.” I was also very concerned that appropriate steps had not been taken to ensure understood the nature of one of the most significant risks of VBAC.
Circumstances of the Death
The background to Mabel’s fatal hypoxic injury is set out above. She sadly died 6 days later in the Neonatal Intensive Care Unit of a hospital in Bristol.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.