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Court ref: GLW-B1053-22
RESPONSE
BY GREATER GLASGOW & CLYDE HEALTH BOARD
to the
DETERMINATION OF SHERIFF BARRY JOHN DIVERS
[2025] FAI 25
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016
into the deaths of
FREYA MURPHY
To: Scottish Courts and Tribunals Service
1. Greater Glasgow & Clyde Health Board, being a participant in the inquiry and being an organisation to whom recommendations under section 26(1)(b) were addressed, responds to the Court’s two recommendations as follows.
Recommendation 1
Greater Glasgow Heath Board (GGHB) should review staffing levels across all shifts to ensure that its labour wards, post- natal wards, maternity assessment units and other hospital maternity related areas are adequately staffed at the weekend and in the evening such as to allow, in the case of an emergency where two patients require admission to theatre at the same time, for the opening of a second operating theatre, within a suitably expeditious time and where such a second theatre is available.
Response
NHSGGC regularly reviews staffing levels to ensure all maternity services are appropriately staffed. This is managed on a day-to-day basis, including weekends, through site safety huddles and cross-site touch point calls. A key part of each Labour Ward Co-ordinator’s role is to manage staff numbers and skills to safely run two emergency Obstetric theatres when required to do so. The Medical resources to do so are built into the Medical Rotas for the specialties of Obstetrics and Anaesthesia.
Our workforce plan prioritises maternity services. This is reflected in the staffing base we recruit to; its focus is to ensure that safe staffing levels in triage, labour ward, theatre and inpatient areas are successfully delivered across our maternity sites. This is subject to annual review.
Recommendation 2
GGHB should formerly (sp) request that the United Kingdom National Screening Committee (UKNSC) give urgent consideration to a review of whether pregnant women routinely be offered screening for Group B Streptococcus ( “GBS”). That if such a review is under way, then a copy of this determination be provided to the UKNSC for consideration in that review.
Response
In line with the FAI recommendation on this matter, NHSGGC has made the formal request to the UK National Screening Committee (UKNSC) to urgently consider a commissioned review of whether there should be routine screening of pregnant women for Group B Streptococcus (GBS). In the event that a review is already underway, we have supplied a link to the Court’s determination and asked that the Court’s determination is considered in the course of that review. Our current GBS procedures were not subject to a recommendation however we acknowledge that the issue of universal screening for GBS in pregnancy remains the subject of scientific debate. In addition to making this formal request, NHSGGC has offered to assist UKNSC with their review.
2. Concluding comments
NHSGGC is fully committed to learning from this tragic case and to implementing in full the two recommendations from the FAI. A report about this FAI Determination was submitted to the NHSGGC Board at the Board meeting on 24 June 2025. The Board will continue to monitor the impact of these recommendations as implemented.
22 July 2025