Jannat Abbker: Prevention of Future Deaths Report

1. The President 
Royal College Obstetricians and Gynaecologists (RCOG)
10-18 Union Street 
London SE1 1SZ 

I am: Coroner ME Hassell 
Senior Coroner  
Inner North London 
St Pancras Coroner’s Court
Camley Street 
London  N1C 4PP 

I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 

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. 

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. 

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.

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? 

In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.  

You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 June 2025.  I, the coroner, may extend the period. 
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 

I have sent a copy of my report to the following.

Jannat’s parents
HHJ Alexia Durran, the Chief Coroner of England & Wales

I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.

I may also send a copy of your response to any other person who I believe may find it useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she  believes  may  find  it  useful  or  of  interest.  You  may  make representations to me, the coroner, at the time of your response, about the release or the publication of your response.