Dear Ms Persaud, Re: Inquest touching upon the death of Mrs Hurrun Maksur - Preventing Future Deaths Report Thank you for your request dated 15 December 2021 . "The Resuscitation Counci\ UK jRCUK) has reviewed the Regulation 28 (Preventing Future Deaths) Report and case summary prov·1ded. The RCUK has been specifically asked to incorporate the MBRRACE UK 2019 Guidance that states: 'Women of reproductive age, presentrng to the ED' cottapsed, in w'norn a pdrmonaryemDo'rism is suspected, should have a Focussed Assessment with Sonography in Trauma {FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia.• The RCUK response below has been led by Dr , Chair of the ALS Subcommittee and Subcommittee members Dr and Dr .
1. The RCUK updates its guidelines on a regular basis using a process that is accredited by the National Institute for Health and Care Excellence (NICE). The most recent update was in May 2021. With regards the use of sonography (ultrasound is the mare common\y used term), the \atest 202--\. the RCUK guidelines include:
a. A greater emphasis on the use of ultrasound during Advanced life Support (ALS) to identify and treat reversible causes of cardiac arrest 1rus appUe.~ ID a\\. cardi.ac:. ;yews ~~j_-11-,;;,\. for the pregnant patient. This is specifically mentioned in the reversible causes part of t'ne resus.org.uk 5th Floor, Tavistock House North enquiries@resus.org.uk Tavistock Square, London WClH 9HR

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g Resuscitation Council UK ALS algorithm. See https://www.resus.orq.uk/library/2021-resuscitation-guidelines/adult­ advanced-life-support-guidelines
b. Specific guidelines for cardiac arrest rn the pregnant patient induding •identify and treat reversible causes (e.g. haemorrhage). Focused ultrasound by a skilled operator can be used to identify reversible causes and may also be used to assess if a fetal heart rate is present.• See https://www.resus. orq. uk/library/2021-resuscitation-qu idel ines/special-ci rcumstances­ g uidel ines
2. The RCUK Advanced Life Support Manual (8th Edition, May 2021) includes the following regarding haemorrhage: Reversible causes of collapse and cardiac arrest in pregna1ncy Look for reversible causes using the 4 Hs and 4 T s approach. Abdominal ultrasound by a skilled operator to detect possible causes during cardiac arrest can be! useful. 1t can also permit an evaluation of feta/ viability, multiple gestations {twins) and plaCEmtal localisation. nshou1d not however delay treatments. Specific reversible causes of collapse or cardiac arrest in pregnancy include: Haemorrhage This can occur both antenatally and postnatatly. Causes include ectopic pregnancy, placental abruption, placenta praevia, abnormal placentation {incretal percreta) and uterine rupture. Maternity units should have a massive haemorrhage protocol. Treatment is based on the ABCDE approach. The key step is to stop the bleeding.
3. RCUK Advanced Life Support Manual {8th Edition, May 2021) includes the following regarding pulmonary embolism in pregnancy: Pulmonary embolism Pulmonary embolism causing cardiopulmonary collapse can present throughout pregnancy . CPR is started with modifications as necessary. The use of fibrinolytic therapy needs considerable thought, particularly if a peri-mortem caesarean section is beintJ considered {see below). If the diagnosis is suspected and maternal cardiac output cannot be restored it should be given.
4. The RCUK ALS subcommittee's opinion is that the issues raised '.Dy the MBBRACE report and the Inquest are addressed in the most recent RCUK guidance and teaching materials. Speciflca\\y: resus.org.uk 5th IFloor, Tavistock House North enquiries@resus.org.uk Tavistock Square, London WClH 9HR

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a. Firstly, RCUK is mindful that its guidelines address allcardiac arces~arnHna'i..ma\ema\ cardiac arrests make up a very small proportion these arrests. \n addition the specia\ist skins and equipment required for ultrasound during resuscitation are not a\ways immediate\y available in all settings. Any changes therefore need to be proportionate and recognise t'ne risks of delaying time critical treatments such as flbrino\ysis "in patients with a suspected PE.
b. Active major bleeding (haemorrhage) is a contraindication for thrombolytic {frbrino\ytic) drugs regardless of the cause of bleeding or the patient group. This risk of bleeding with fibrinolytic drugs (which dissolve clots and prevent clotting) shou\d a\ready be known to those who use them. The section of the RCUK Advanced tife SapportManua~ tath E<:Mi'arr, Ma,r2fl~1ns'ls contraindications to fibrinolytic therapy - active internal bleeding is an absolute contraindication.
c. In addition to an ectopic pregnancy, there are a number of causes of co\\apse from b\eeding in the pregnant patient and these are highlighted in the current teaching materials.
d. There is already a strong emphasis on the use of u\trasound to look for reversible causes including haemorrhage in RCUK guidelines and teachin9- ma~-er1a\.c;, ror B\\. cau~s... ~~4:~ arrest including cardiac arrest during pregnancy.
5. To address the variance with the MBRRACE UK 2019 guidance, RCUK will further emphasise the need to exclude major bleeding as the cause of collapse before giving iibrino\ytic drugs tor suspected PE in pregnancy. We will also consider other teaming from this case. "The following areas wll'I 'oe reviewed and updated as necessary:
a. Next print run of RCUK Advanced Life Support Manua\ (8th Edition, May 2021).
b. Teaching materials on the ALS course concemlng pregrrancy.
c. Obstetric Cardiac Arrest Quick Reference Handbook in col\aboration with MBBRACE and the Obstetric Anaesthetists Association.
6. The RCUK will share this response with: resus.org.uk 5th Floor, Tavistock House North enquiries@resus.org.uk Tavistock Square, London WClH 9HR

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a. The Royal College of Obstetricians and Gynaecologists. arul1 \ia~e. '44\\'n'me.~_sw..~~9--­ whether further updates are required.
b. The ALSG that oversees the Managing Medical and Obstetric Emergencies and "Trauma (mMOET) course.

Dear Miss Persaud Re: Regulation 28 Report into the death of Mrs Hurrun Maksur

Thank you for your Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mrs Hurrun Maksur dated 15th December 2021. We would like to begin by extending our sincere and heartfelt condolences to Hurrun's family for their deep loss. We recognise and respect the narrative conclusion from the inquest. In your report you raised two concerns:
1. Concern was raised during the course of the inquest in relation to the reference to the FAST scan. It was considered that reference should be to a point ofcare ultrasound scan, as trauma is not necessary a pre-condition for the scan to take place.
2. That obstetricians do not receive specific training to identify intra-abdominal bleeding'. In order to provide a full response, we have been in touch with colleagues at The Association of Early Pregnancy Units, as well as with Senior College Officers and our Curriculum Committee (responsible for core training in Obstetrics and Gynaecology) Screening for ectopic pregnancy is a mandatory part of the ultrasound assessment in early pregnancy. Anyone undertaking a scan in early pregnancy must check for a potential ectopic pregnancy. This is specifically stated in our advice regarding ultrasound training: ultrasound­ scan--guidance-vfinal.pdf (rcog.org.uk) Most of the routine scans in early pregnancy within antenatal services are carried out by ultrasonographers rather than consultants or trainees in Obstetrics and Gynaecology (O&G}. Excluding ectopic pregnancy is a routine part of the first scan, although the scan is not usually carried out until 11-12 weeks' gestation. In clinical practice, nearly all patients with ectopic pregnancies will have presented to gynaecology emergency services by the time that scan is due to be undertaken and it is rare for an ectopic pregnancy to be diagnosed that late in pregnancy. Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London SE 1 1 SZ T: +4-1 (0) 20 /772 6200 W: rcog.org.uk S: @RCObsGyn ':I' • '

Royal College of Obstetricians &
• Gynaecologists Within gynaecology emergency services, scanning is undertaken by a mixture of ultrasonographers trained by and working within radiology departments and O&G doctors; in any case they are all trained to check that the pregnancy they are observing is intrauterine. However, there are very few, if any, Trusts in the UK with emergency gynaecology service provision which relies on ultrasonography being carried out solely by O&G doctors. The assessments required of trainees within our core curriculum involve transabdominal scanning in early pregnancy. The College has had much discussion about transvaginal scanning as part of the core and basic curriculum, but because most ultrasound examinations are carried out by ultrasonographers we subsequently did not put this into the curriculum as a specialist skill. If a woman presents with a ruptured ectopic pregnancy, the expectation would be that the woman would be seen as an emergency, a clinical assessment made and a decision about urgency taken. The woman can be taken to theatre without a scan if urgent surgery is thought to be life-saving. This is outlined in our Capability in Practice (CiP) 9 where we state that trainees should "Formulate an appropriate and individualised management plan taking into account a person's preferences and the urgency required." Because of the way that ultrasound services are set up in the UK i.e. there is no clinical need (and sometimes no opportunity) for O&G doctors to routinely perform early pregnancy scans, RCOG educators have not sought to train all our junior doctors to independent competence level and have added the following caveat to the curriculum: 'Completion of the two mandatory transabdominal ultrasound skills does not imply that a trainee is automatically ready for independent practice in diagnostic ultrasound (particularly in out ofhours unsupervised clinical settings). Care should be taken in delegating decisions about clinical management of patients to trainees who have completed only the mandatory modules (particularly where management relies on the ultrasound findings). The expected utilisation of ultrasound skills, both within and out of hours should be determined and agreed by the local ultrasound supervisor in the context oflocal protocols for ultrasound scanning.' With reference to the second concern, transabdominal ultrasound scan in the first trimester is utilised to confirm the intrauterine site of the pregnancy and the presence of a feta I heartbeat. It is routine and part of the training to note how much free fluid is present in the pelvis, and whether the fluid identified resembles blood or peritoneal fluid. The implications are that if the pregnancy is not intrauterine, you would look for a bleeding ectopic pregnancy. We acknowledge that in the responses raised there was a concern about the timely recognition of intraperitoneal bleeding. Bleeding from a ruptured, or more commonly leaking, ectopic pregnancy is often slow and the blood clots in the peritoneal cavity. This means that there is not much 'free fluid' and the clotted blood looks very similar to loops of bowel. A young fit woman may deteriorate at a late stage and may have an abdomen full of clotted blood that is missed on a portable transabdominal scan looking for fluid. This is a different situation from identifying intra-abdominal bleeding later in pregnancy. Roya I College of Obstetricians and Gynaecologists, 10-18 Union Street, London SE 1 1 SZ T: +44 (0) 20 7772 6200 W: rcog.org.uk S: @RCObsGyn 1 ,u UC ' j

Royal College of Obstetricians & Gynaecologists Later in pregnancy, or in the situation where the gestational age is unknown (such as a concealed pregnancy) scans may be undertaken by a variety of personnel but in most cases within an obstetric setting such as on labour ward or a gynaecology setting such as an early pregnancy unit, this would be experienced ultrasonographers trained and working within radiology departments. ' RCOG is supportive of the guidance from MBRRACE UK (2019) which states: Women of reproductive age, presenting to the ED collapsed, in whom a pulmonary embolism is suspected, should have a Focussed Assessment with Sonography in Trauma (FAST) scan to exclude intra-abdominal bleeding from a ruptured ectopic pregnancy especially in the presence of anaemia. In A&E, abdominal scanning is usually performed by doctors working within the A&E department who are trained to look for intra-abdominal bleeding; for example in cases of abdominal trauma, ruptured arterial aneurysms etc. It is very rare indeed for an obstetric doctor to be carrying out such a scan within an A&E department and most obstetric doctors would go through their whole hospital career without being asked to perform an ultrasound I! in these circumstances. Because of the lack of opportunities within routine O&G clinical practice, it would not be feasible to train all our doctors to be able to do this reliably even using simulation. Not only would it be difficult to organise training, they would not be able to retain their skills by regular practice - unlike doctors working in A&E. It would be better to focus training efforts on those doctors who perform this sort of scan (a FAST scan) on a routine basis. Whilst the O&G doctors should clearly be part of the team making decisions about the care of a collapsed pregnant woman, they are likely to be the least experienced in terms of performing the FAST scan. It is our intention to engage in discussions with educators from the Faculty of Emergency Medicine and the Royal College of Radiologists to reinforce the need to check for intra­ abdominal bleeding before anticoagulating a collapsed patient. Additional information on training In addition to the above, the following information provides further clarity on our training in this area: As above in point 1, competencies are outlined in CiP 9: The doctor is competent in recognising and managing emergencies in gynaecology and early pregnancy' (pages 19 and 20 in the Definitive Document for the Core Curriculum). There are further competencies outlined in CiP 11: The doctor is competent in recognising, assessing and managing emergencies in gynaecology and early pregnancy' (pages 23-25 in the Definitive Document for the Core Curriculum). Roya I College of Obstetricians and Gynaecologists, 10-18 Union Street, London SE 1 1 SZ T: +44 (0) 20 7772 6200 W: rcog.org.uk S: @RCObsGyn .-<, 'J " ! c, ., L.:m

Royal College of Obstetricians & Gynaecologists It is expected that O&G trainees are able to independently perform Transabdominal ultrasound examination or early pregnancy, as confirmed by three summative competent OSATS (page 44, Definitive Document for the Core Curriculum}. ' The detailed knowledge criteria for CiP 9 appears in knowledge areas 3 and 13 in our MRCOG membership examination: MRCOG knowledge requirements: Area 3 - core surgical skills MRCOG Knowledge requirements: Area 13 - early pregnancy care The detailed knowledge criteria for CiP 11 appears in knowledge areas 10, 11, 12, 14 and 15. We hope that this provides further clarity on the above training queries and demonstrates that the RCOG is committed to improving the standard of care provided for women and working collaboratively with others to prevent tragedies like this in the future.