Dear Mr Pollard Re: Antonio Jerome ALLEN (Deceased) Thank you for your letter to Sir Michael Deegan of 31st 2014, he asked me to on his behalf: instructed the clinical team to review the case and haveasea oectheearsveery to the points noted in the Regulation 28 notification below. The priority of the maternity directorate is to provide safe and high quality maternity care for allwomen and their partners regardless of their choice of place of birth: Options for place of birth are discussed with the woman and her partnerlfamily to enable women to make an informed choice At the booking consultation a full medical, surgical, obstetric and social is taken to support women in their decision by discussing the risks and benefits of choices available: Women are also given an information leaflet to enable them to discuss their options further with their family: Maternity staffing is managed to ensure that the community midwifery team can respond to requests from women at any time of the day or night when a home birth is planned in order to ensure women and their family receive optimal care and support. On the 17th June 2013 at approximately 04.20 hours community midwifel was informed by fellow midwife, working on the midwifery led unit; of the imminent delivery at home address_ Midwifel Jimmediately collectedtthe emergency equipment and attended Patient A's home_ On arrival at 04.44 hours was on the kitchen floor with her baby placed on her abdomen (skin to skin). Midwife performed a full risk assessment once and her baby Were comfortable and settled and made the decision that it was safe for both to remain at home. The mother of informed Midwife Jthat she had telephoned the dedicated telephone number approximately 04.00 on four occasions until approximately (04.20
04.30 hours) but her call was not answered: (All women who are booked for a planned home birth are given a dedicated number to contact, This telephone line is normally in operation 24 hourslday). mother reported that she then called the department who transferred her calrto the community midwifery team: INVESTORS Manchester Royal Eye Hospital Manchester Rcporanfmnary Royal Manchester Children'$ IN PEOPLE Saint Mary'$ Hospital Trafford Hospitals University Dental Hospitasoe Mancheste Hospital Community Services Di5aBLt9 July has fully history from Triage #our 6 1

Central Manchester University Hospitals NHS] NHS Foundation Trust Following her return to the hospital Midwife lalerted the radio telephone administration staff of the difficulties experienced by the family: On investigation it was identified that there had been a known fault on the telephone line earlier in the day but this had been resolved by the engineers_ There is a process in place to ensure that the essential telephone lines are checked at the beginning of each shift; it was apparent that the administrator did not follow the process for checking the phone line at commencement of their shift so was unaware that the fault had reoccurred. On informed by Midwife lof the unanswered phone calls the administrator notified switchboard of the fault on the line and immediate action was taken to reconnect the telephone line_ To ensure that this never happens again women are now given two telephone numbers to call in case one line is busy or faulty standard in piace to check that the essential telephone liney areafuily functioning operating procedure