Jannat Abbker
PFD Report
All Responded
Ref: 2025-0203
All 1 response received
· Deadline: 20 Jun 2025
Coroner's Concerns (AI summary)
A successful obstetric manoeuvre, the "shoulder shrug," is not included in NICE guidelines despite its use abroad, indicating a potential omission for future guideline updates.
View full coroner's concerns
With the benefit of a maternity and newborn safety investigation (MNSI), UCLH is undertaking a significant piece of work to improve its systems.
However, there remains one outstanding point. When all else had failed, Jannat was finally delivered by use of a manoeuvre called a shoulder shrug. I heard at inquest that this is not a manoeuvre included within the NICE (National Institute for Health and Care Excellence) guidelines, but it is used abroad. One of the obstetric registrars looking after Jannat’s mother had seen it in a training video.
I wonder if there is merit in considering this for inclusion in the next set of relevant NICE guidelines, whenever these are updated?
However, there remains one outstanding point. When all else had failed, Jannat was finally delivered by use of a manoeuvre called a shoulder shrug. I heard at inquest that this is not a manoeuvre included within the NICE (National Institute for Health and Care Excellence) guidelines, but it is used abroad. One of the obstetric registrars looking after Jannat’s mother had seen it in a training video.
I wonder if there is merit in considering this for inclusion in the next set of relevant NICE guidelines, whenever these are updated?
Responses
Noted
The RCOG expresses condolences and explains their guideline development process, stating that the Shoulder Dystocia guideline will be updated to include a section on alternative maneuvers but that there is not currently enough evidence to recommend the shoulder shrug maneuver. They emphasize the importance of effective training using existing recommended maneuvers. (AI summary)
The RCOG expresses condolences and explains their guideline development process, stating that the Shoulder Dystocia guideline will be updated to include a section on alternative maneuvers but that there is not currently enough evidence to recommend the shoulder shrug maneuver. They emphasize the importance of effective training using existing recommended maneuvers. (AI summary)
View full response
Dear Ms Hassell
Re: Baby Jannat Abbker Your ref:
Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Jannat Abbker on 25 April 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 Jannat’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 that Jannat died as a consequence of trauma suffered during birth as a result of shoulder dystocia.
We also recognise the matters of concern as outlined in your letter as follows, Jannat was finally delivered by use of a manoeuvre called a shoulder shrug. I heard at inquest that this is not a manoeuvre included within the NICE (National Institute for Health and Care Excellence) guidelines, but it is used abroad. One of the obstetric registrars looking after Jannat’s mother had seen it in a training video. I wonder if there is merit in considering this for inclusion in the next set of relevant NICE guidelines, whenever these are updated?
The RCOG supports doctors to deliver maternity services through its educational initiatives. This encompasses developing curricula, elevating care standards through clinical guidance, assisting in career advancement through examinations, coordinating professional development initiatives and events, and offering support services to its members.
The RCOG Green Top Guideline (No. 42) on Shoulder Dystocia is due to be updated and published this year. This update has been in production for the last two years and is undergoing extensive development including comprehensive literature searches, internal and external review, involvement of key stakeholders and liaison with multi-professional specialists and experts. There is no NICE guidance on this topic and national guidelines are produced either by the RCOG or NICE to avoid replication.
Relevant to the index birth, the guideline makes recommendations about mode of birth after a previous history of shoulder dystocia and delivery by planned caesarean birth is one of the recommended options, as referenced in your report.
Intrapartum stillbirth is extremely rare at shoulder dystocia and current training programmes and the correct use of the release manoeuvres are as per the algorithm in the RCOG guidance. Reviewing the evidence, there are more than 100,000 vaginal births reported in the literature by training teams in the UK, United States, Spain and Germany with no permanent brachial plexus injury post shoulder dystocia (usual rate 3 per 10,000 vaginal births) and no intrapartum stillbirths. All these multi-professional teams used the clinical algorithm laid out in the RCOG Green-Top Guideline.
There are other manoeuvres outside of those listed in the RCOG guidance as reported in the literature, for consideration, when the routine release manoeuvres have been unsuccessful. However, the data and evidence supporting these manoeuvres are extremely limited.
The updated Shoulder dystocia guideline will include a section on ‘alternative manoeuvres’ based on good quality interventional research before making any new recommendations. We can confirm that the evidence for shoulder shrug has been considered, but the lead developers do not feel that there is sufficient evidence to currently recommend it in our evidence based RCOG management algorithm.
However, effective training to manage shoulder dystocia using the mentioned release manoeuvres continues to be recommended and is also incentivised through the NHS Resolution Maternity Incentivisation Scheme to reduce morbidity and mortality to a minimum.
Thank you for bringing this to our attention. I hope this is a helpful response to this matter.
Re: Baby Jannat Abbker Your ref:
Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Jannat Abbker on 25 April 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 Jannat’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 that Jannat died as a consequence of trauma suffered during birth as a result of shoulder dystocia.
We also recognise the matters of concern as outlined in your letter as follows, Jannat was finally delivered by use of a manoeuvre called a shoulder shrug. I heard at inquest that this is not a manoeuvre included within the NICE (National Institute for Health and Care Excellence) guidelines, but it is used abroad. One of the obstetric registrars looking after Jannat’s mother had seen it in a training video. I wonder if there is merit in considering this for inclusion in the next set of relevant NICE guidelines, whenever these are updated?
The RCOG supports doctors to deliver maternity services through its educational initiatives. This encompasses developing curricula, elevating care standards through clinical guidance, assisting in career advancement through examinations, coordinating professional development initiatives and events, and offering support services to its members.
The RCOG Green Top Guideline (No. 42) on Shoulder Dystocia is due to be updated and published this year. This update has been in production for the last two years and is undergoing extensive development including comprehensive literature searches, internal and external review, involvement of key stakeholders and liaison with multi-professional specialists and experts. There is no NICE guidance on this topic and national guidelines are produced either by the RCOG or NICE to avoid replication.
Relevant to the index birth, the guideline makes recommendations about mode of birth after a previous history of shoulder dystocia and delivery by planned caesarean birth is one of the recommended options, as referenced in your report.
Intrapartum stillbirth is extremely rare at shoulder dystocia and current training programmes and the correct use of the release manoeuvres are as per the algorithm in the RCOG guidance. Reviewing the evidence, there are more than 100,000 vaginal births reported in the literature by training teams in the UK, United States, Spain and Germany with no permanent brachial plexus injury post shoulder dystocia (usual rate 3 per 10,000 vaginal births) and no intrapartum stillbirths. All these multi-professional teams used the clinical algorithm laid out in the RCOG Green-Top Guideline.
There are other manoeuvres outside of those listed in the RCOG guidance as reported in the literature, for consideration, when the routine release manoeuvres have been unsuccessful. However, the data and evidence supporting these manoeuvres are extremely limited.
The updated Shoulder dystocia guideline will include a section on ‘alternative manoeuvres’ based on good quality interventional research before making any new recommendations. We can confirm that the evidence for shoulder shrug has been considered, but the lead developers do not feel that there is sufficient evidence to currently recommend it in our evidence based RCOG management algorithm.
However, effective training to manage shoulder dystocia using the mentioned release manoeuvres continues to be recommended and is also incentivised through the NHS Resolution Maternity Incentivisation Scheme to reduce morbidity and mortality to a minimum.
Thank you for bringing this to our attention. I hope this is a helpful response to this matter.
Sent To
- Royal College Obstetricians and Gynaecologists
Response Status
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56-Day Deadline
20 Jun 2025
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 23 August 2024, one of my assistant coroners, Edwin Buckett, commenced an investigation into the death of Jannat Abbker, a baby who died shortly after birth. The investigation concluded at the end of the inquest yesterday. I made a determination at inquest that Jannat died as a consequence of trauma suffered during birth as a result of shoulder dystocia.
Circumstances of the Death
Jannat was a big baby and her mother had a history of shoulder dystocia with two out of her three previous pregnancies. Her mum received midwifery and obstetric care for the two pregnancies at University College London Hospital (UCLH), and Jannat was delivered there. Unfortunately, the fact of the shoulder dystocia was not communicated to Jannat’s parents after the earlier births, and was not recognised by the staff at UCLH during this pregnancy. If it had been, Jannat’s mother would have been offered a Caesarean section for Jannat’s delivery. A Caesarean section would have avoided the shoulder dystocia that caused Jannat’s death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.