Dear Mr Osborne Regulation 28: Report to Prevent Future Deaths I write in response to the Regulation 28 report you issued on 20 October, following on from the Inquest held into the death of Poppy Harris (on 24 March 2021) which concluded on 15 October 2021 . This report was issued to me, and a further report was issued to the Royal College of Obstetrics and Gynaecology (around the place of Kielland's forceps in modern obstetric practice more generally). The loss of a healthy baby is of course profoundly sad, particularly in this context where a clear link can be drawn between an assisted I interventional delivery and injuries sustained. Our thoughts remain with Poppy's parents and wider family. You raised two specific issues which I shall address in turn:
1. When Poppy's mum came into the hospital, she did not have a birth plan and the midwives did not attempt to complete one. There was therefore no indication as to her preferences for treatment and care throughout her labour. There are two contextual factors which should be considered:
a. MKUH, and many other NHS organisations, are adopting. electronic health records (in our case, Gerner). There are substantial patient safety benefits. In maternity care, a specific challenge arises as the electronic health record was preceded by a paper record held (predominantly) by the mother rather than the hospital. We continue to work to optimise the balance between the risks and As o leaching hospitol. we conduct education ond research to improve heolthcare for our patients. During your visil students may be involved in your care, or you moy be osked 10 porticipale in a clinical trial. Please speak to your doctor or nurse If you have any concerns.

TheMK
t.!t:kj Cl.Re COMMUN1CA.T'E. Milton Keynes COUAIO ~wrt. University Hospital NHS Foundation Trust benefits of an electronic health record and the (appropriate) requirement for mothers to have ready access to their record .
b. The ongoing COVID-19 pandemic continues to have an impact on the maternity pathway (specifically in relation to the use of virtual platforms for some traditionally physical maternity contacts). Following on from Poppy's inquest- and recognising the need to take stock following on from iterative changes to maternity pathways over the course of the COVID-19 pandemic - we have undertaken a review of how we ensure that women's birth preferences are discussed and documented. As part of their routine antenatal care, women are seen by their community midwife at approximately 30 weeks of pregnancy (precise timing varies according to first / subsequent pregnancy), and again at 34 weeks. Going forward, this area will be addressed specifically at these two points. At the 30-week appointment, women will be provided with access (via an internet URL/ QR code) to a specific section on the MKUH maternity website where a repository of leaflets relevant to aspects of birth, along with short videos about each of the topics, will be placed. These leaflets and videos will include - but will not be limited to:
• Meet the team
• Pain relief in labour Waterbirth
• Epidural
• Monitoring your baby's heartbeat
• Assisted vaginal birth (RCOG)
• Caesarean section
• OASI (obstetric anal sphincter injury)
• Perineal care
• Vitamin K
• Newborn feeding The woman will be encouraged to read the leaflets and/or review the videos in preparation for a structured discussion about birth preferences at the 34-week appointment. As o teaching hospttol, we conduct educolion end ieseorch IO improve heolthcore fOf our polients. During your visit students moy be involved in your core, or you moy be oslced to participate in o clinical trlol. Please speak to your doctor or nurse if you hove any concerns.

TheMK ,~,:~j CARf. COMt.AUMICATE. Milton Keynes COUAll()i:., CON1RIBVT'E. University Hospital NHS Foundation Trust At 34 weeks, the length of the appointment will be extended from 20 minutes to one hour. In this time, the midwife will complete the routine antenatal checks and discuss the woman's questions, wishes and birth preferences, recording this on a standardised form. The design of the form will have input from the local Maternity Voices Partnership. We will keep abreast of regional and national initiatives and consider reverting to a standardised process as and when established. In the first instance, the form will be completed by the midwife within the electronic patient record, and a printed copy will be given to the woman for inclusion within her handheld record. We will ensure that particular care is taken to facilitate this 34-week discussion (and share the underlying information resources) for those with disabilities and/or for whom English is not a first language.
2. Poppy was delivered by the use ofKie/land's forceps that resulted in a catastrophic spinal cord injury. I believe the hospital should carry out an urgent review of the use ofKie/land's forceps and decide that they should not longer be used. As you are aware, Kielland's rotational forceps are used by a subset of obstetricians in England (i.e., the use of Kielland's rotational forceps is not a required competency for all consultant obstetricians). Their use tends to be concentrated in some units and they may be absent in others. As with most interventions, professional opinion and some evidence supports a relationship between volume and outcomes: in capable and experienced hands, Kielland's rotational forceps can assist in achieving safe vaginal delivery thus reducing the need for emergency Caesarean section (and the risks that this carries for the mother in particular). In recent years, two consultant practitioners at MKUH have been regular users of Kielland's forceps in appropriate cases. The use of Kielland's at MKUH has been paused since Poppy's delivery on 23 November 2020. Whilst we naturally seek to take on any learning from Inquest findings, the local Coronial process is not in my view the appropriate route through which to determine future patterns of medical practice. Such decisions require appropriate assessment of risks and benefits of multiple treatment modalities, drawing upon evidence and professional opinion. We will await the response of RCOG to your Regulation 28 report with interest and will determine our position at that point. As a teaching hospital, we conduct education and research la improve healthcare lo, olK patients. During your visit students may be involved in your care, oryou may be asked lo particlpole in a clinical trial. Please speak lo your doctor or nurse if you hove any concerns.

TheMK y ,~1:f1
c.:, COM.WJHICAT'E. Milton Keynes COUAIOlli a>NTIQtJTE_ University Hospital NHS Foundation Trust I believe that it is unlikely that RCOG will advocate the removal of rotational forceps from practice. In that event, and if individual clinicians wish to maintain the option of rotational forceps in their repertoire, we will support them in doing so. We will of course ensure that discussions are held in appropriate fora (departmental clinical governance meetings and individual professional appraisal) to ensure that knowledge, skills, and volumes meet recommendations of RCOG and/or regional obstetric leads. If consultant practitioners continue to use Kielland's forceps, we will also permit them to train junior colleagues in their use (taking into account relevant guidance from Health Education England and others). I hope that this response is helpful.