Jannat Abbker

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

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.