Jump to content
  • Prevention of Future Deaths report – Rhian Rose (3 November 2021)

    • UK
    • Reports and articles
    • Pre-existing
    • Public domain
    • No
    • Nicholas Lane
    • 03/11/21
    • Everyone


    Rhian Rose underwent feticide on 22 November 2019 and was admitted to a maternity ward on 24 November 2019 for medical termination of pregnancy. By the evening of her admission, Rhian had clear symptoms of infection, however the sepsis pathway and antibiotics were not commenced until the following morning. In the late afternoon on 25 November 2019, Rhian became acutely unwell resulting in unconsciousness, emergency caesarean section, subsequent cardiac arrest and eventually her death.

    In this report the Coroner raises concerns about a lack of informed consent and discussion of maternal wishes and the mode of delivery highlighted by this case. He highlights a lack of guidance relating to the infection risk when a mother is attending for delivery following feticide.


    In her report, the Coroner states his main concerns as follows:

    Informed consent and maternal choice regarding mode of delivery

    • That this appears to be a recurring theme in obstetric practice. The culture in this area appears to still not fully accept the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section). It also does not seem to prioritise the wishes of pregnant women or holding full and frank discussions about the risks and benefits and pros and cons of different options.
    • He noted that he had concerns that situations might arise, like it appears happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health.
    • Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussion held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk and benefits of differing management plans.

    Infection risk of retained foetus following feticide

    • That a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical decisions when a mother is attending for delivery (following feticide).
    • There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach.
    • That while cases such as Rhian’s may be rare, consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide.

    This report was sent to Worcestershire Acute Hospitals NHS Trust, Birmingham Women and Children’s Hospital NHS Trust, the Royal College of Obstetricians and Gynaecologists and the Healthcare Safety Investigation Branch.

    Prevention of Future Deaths report – Rhian Rose (3 November 2021) https://www.judiciary.uk/publications/rhian-rose-prevention-of-future-deaths-report/
    0 reactions so far


    Recommended Comments

    There are no comments to display.

    Create an account or sign in to comment

    You need to be a member in order to leave a comment

    Create an account

    Sign up for a new account in our community. It's easy!

    Register a new account

    Sign in

    Already have an account? Sign in here.

    Sign In Now
  • Create New...