Form  6.2

                              Response

SHERIFFDOM OF GLASGOW AND STRATHKELVIN AT

GLASGOW

Court ref: GLW-B1011-23

RESPONSE

BY GREATER GLASGOW & CLYDE HEALTH BOARD

to the

DETERMINATION OF SHERIFF PRINCIPAL A Y ANWAR KC

[2025] FAI 15

UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016

into the deaths of

LEO LAMONT, ELLIE McCORMICK AND MIRA-BELLE-BOSCH

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 eleven recommendations as follows.

Recommendation 1

Greater Glasgow & Clyde Health Board (“GGCHB”) should develop a trigger list or similar system to (a) aid in the identification and assessment of symptoms that might be indicative of preterm labour and (b) inform a decision as to whether a patient should attend for clinical assessment. When a telephone assessment is carried out with a patient presenting with any symptoms of preterm labour, a list of relevant enquiries should appear on BadgerNet, similar to those that appear for conditions such as: term labour; reduced fetal movement; and rupture of membranes. GGCHB should conclude the development of a guideline for preterm labour as soon as possible. Each of these measures should specify a low threshold for attendance for clinical assessment to reflect the low threshold for admission and obstetric intervention recommended by the NICE Guideline on Preterm Labour and Birth, November 2015. All health boards that provide maternity services should review their practices and guidelines for the identification and management of pre-term labour.

Response

NHSGGC has already implemented the key recommendation where NHSGGC is identified as the lead, by updating and publishing its new preterm labour and birth guidance (including a ‘trigger list’). This is published on its Right Decisions guidelines platform: Preterm birth (1188) | Right Decisions. This has been shared with all health boards in Scotland.

Recommendation 2

All health boards in Scotland that provide maternity services should review the information displayed on electronic maternity records relating to previous preterm births. They should consider the creation of an automatically generated critical alert for previous preterm labour where one does not exist.

Response

A critical alert for preterm birth is already available on the NHSGGC Badgernet system. National action is required by the company who are the owners and developers of Badgernet to make this automatically generated. See below for further details of how this work will progress

Recommendation 3

All health boards in Scotland that provide maternity services should ensure they have a procedure that requires an existing named midwife to create a handover note upon a planned change of named midwife. The handover note should be stored on BadgerNet, or similar electronic records, and should draw attention, in particular, to any prior complications or risk factors in a woman’s pregnancy to ensure that these are not lost sight of if continuity of care is interrupted.

Response

The recommendation relating to having a procedure to ensure an appropriate handover when there is a planned change of named midwife relates to the NHS Lanarkshire case. NHSGGC action: complete. NHSGGC has a process for ensuring that the named midwife is changed on the Badgernet record.

Recommendation 4

All health boards that provide maternity services should ensure they have a system to allow a note to be added to a patient’s electronic records in order to highlight a further reason for a referral to a pre-existing appointment with a consultant.

Response

The recommendation relating to the additional reasons for a referral to a pre-existing consultant appointment relates to the NHS Lanarkshire cases. This facility is available on Badgernet, however, the focus for improvement in these cases is on the ease with which a practitioner can access information readily on Badgernet during a short appointment.

National action is required (by the company who own and develop Badgernet) to make key information very readily available. This will be part of the national discussion with the company discussed further below.

Recommendation 5

The Electronic Record Keeping Guidance and Audit Tool issued by the Royal College of Midwives should be reviewed to address situations in which midwives may not have access to electronic notes when triaging patients. Guidance should be developed providing that ordinarily, calls from expectant mothers should always be triaged having accessed the patient’s electronic notes. Where that has not been possible, the guidance should provide that midwives should access the notes as soon as possible, complete a note of the communication and review the obstetric history to ensure that the advice dispensed was correct. If the advice requires to change in light of the information contained in the electronic notes, the patient should be contacted with further advice as soon as possible. Healthcare professionals assessing or triaging patients should require to confirm and record on BadgerNet (or similar electronic system) that that they have reviewed and considered the obstetric history before providing advice

Response

This recommendation is for the Royal College of Midwives. The timescale for RCM completion of this action is unclear, but it is understood that RCM is aware of the recommendation and is already working on the issue. NHSGGC is committed to sharing and encouraging use of the revised RCM guidance and audit tool once completed.

Recommendation 6

All health boards that provide maternity services should consider acquiring hand held ultrasound scanners to detect the presentation of the fetus when a women reports spontaneous rupture of membranes or attends for induction or augmentation of labour.

Response

This recommendation relates to the NHS Lanarkshire cases. NHSGGC action: partially complete. NHSGGC has invested in handheld scanners and in training for midwives on undertaking presentation scans prior to inductions of labour.

Recommendation 7

System C Healthcare Ltd and all health boards using BadgerNet should consider how the engagement of the presenting part can be better recorded on BadgerNet and specifically, whether an assessment of ballotability should be recorded

Response

This recommendation arises from the NHS Lanarkshire cases. This relates again to required national changes to Badgernet, to be implemented by System C, the company that own and manage Badgernet.

Recommendation 8

Each maternity unit which receives emergency admissions in Scotland should introduce a telephone line for sole use by Scottish Ambulance Service crews giving them direct access to maternity units (“a red phone”). Ambulance crews should be provided with a simple means of identifying the correct telephone number for each red phone in each maternity unit in Scotland.

Response

NHSGGC action: complete. NHSGGC already has a direct telephone line to each maternity unit solely for the use of SAS crews

Recommendation 9

Consideration should be given to the introduction of video facilities to aid communication between paramedics and midwives or obstetricians in emergency situation

Response

This recommendation is being taken forward at a national level, with NHSGGC contributing to the national work

Recommendation 10

Questions posed by healthcare professionals designed to elicit from a patient both a medical or obstetric history and information on current presentation should make it clear that information related to the present and the past is sought. Health Boards should review pre-populated questions on BadgerNet (or similar systems) to ensure that if they are designed to elicit information relating to present and past concerns that is clearly stated.

Response

This recommendation relates to the quality of documentation during Triage calls and national review of Badgernet records.

Recommendation 11

If “worsening advice” is provided by triaging midwives which includes advice to take analgesia and to call back if symptoms do not improve, women should be provided with an approximate timeframe in which to do so.

Response

Again, this recommendation relates to the quality of documentation during Triage calls and national review of Badgernet records. These will be addressed through the national work and through the implementation of BSOTS (Birmingham Symptom Specific Obstetric Triage System) across all three NHSGGC triage unit

Form  6.2

Response

SHERIFFDOM OF SOUTH STRATHCLYDE, DUMFRIES & GALLOWAY AT

GLASGOW

Court ref: GLW-B1011-23

RESPONSE

By LANARKSHIRE HEALTH BOARD

to the

DETERMINATION OF SHERIFF PRINCIPAL A Y ANWAR KC

[2025] FAI 15

UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016

into the deaths of

LEO LAMONT, ELLIE McCORMICK AND MIRA-BELLE-BOSCH

To: the Scottish Courts and Tribunals Service

1.

Lanarkshire Health Board, being a participant in the inquiry and being an organisation to whom a recommendation under section 26(1)(b) was addressed, do respond to the Court’s eleven recommendations as follows.

Recommendation 1

Greater Glasgow & Clyde Health Board (“GGCHB”) should develop a trigger list or similar system to (a) aid in the identification and assessment of symptoms that might be indicative of preterm labour and (b) inform a decision as to whether a patient should attend for clinical assessment. When a telephone assessment is carried out with a patient presenting with any symptoms of preterm labour, a list of relevant enquiries should appear on BadgerNet, similar to those that appear for conditions such as: term labour; reduced fetal movement; and rupture of membranes. GGCHB should conclude the development of a guideline for preterm labour as soon as possible. Each of these measures should specify a low threshold for attendance for clinical assessment to reflect the low threshold for admission and obstetric intervention recommended by the NICE Guideline on Preterm Labour and Birth, November 2015.

All health boards that provide maternity services should review their practices and guidelines for the identification and management of pre-term labour.

Response

NHS Lanarkshire preterm identification and management of Preterm labour guideline is live and in clinical use and is based on the NICE Guideline for Preterm labour and birth published 20^th November 2015 and NICE guideline for Intrapartum care for healthy women and babies updated February 2017. In addition, at the end of June 2023, NHSL Maternity Triage fully implemented Birmingham Symptom Specific Obstetric Triage System (BSOTS) in both telehealth and the Triage clinical area. This system allows Midwives to continue to use their clinical judgement whilst using the BSOT algorithms which includes triggers for preterm labour, reduced fetal movement and rupture of membranes and the immediate care guidance required. The Midwife conducting the initial assessment must categorise the woman as per BSOTS algorithm which aligns to the patients’ clinical status which then enables a clinical prioritisation of care. Core midwives working in Maternity Triage have received the full training package for the use of the BSOTS and the associated documentation.

Recommendation 2

All health boards in Scotland that provide maternity services should review the information displayed on electronic maternity records relating to previous preterm births. They should consider the creation of an automatically generated critical alert for previous preterm labour where one does not exist.

Response

Critical alerts are now documented in BadgerNet as part of the system changes in 2021 and can be visualised on the information banner as part of the pregnancy page summary.  There is a validated list of critical alerts that is automatically pulled through to the Badgernet summary from the pregnancy record. NHS Lanarkshire have reviewed the list of automated alerts that are live in the system and at this time, previous preterm birth is not an automatically generated critical alert. NHSL have requested System C as owners of Badgernet, to create this function. The timeline of when this request will be granted is a minimum 9 months. In the interim, all midwives, as part of the booking appointment will manually input previous preterm Labour as a critical alert onto the banner that is front facing on the pregnancy summary page. This critical alert will be highlighted in red to acknowledge the risk and will be captured in the risk assessment panel as high risk for preterm birth.

Recommendation 3

All health boards in Scotland that provide maternity services should ensure they have a procedure that requires an existing named midwife to create a handover note upon a planned change of named midwife. The handover note should be stored on BadgerNet, or similar electronic records, and should draw attention, in particular, to any prior complications or risk factors in a woman’s pregnancy to ensure that these are not lost sight of if continuity of care is interrupted.

Response

NHS Lanarkshire have reviewed Badgernet to understand the changes required to enable this function. In order to enact the recommendation, NHS Lanarkshire have asked to meet System C with a request when a change of primary midwife occurs this is pulled through onto the mandatory risk assessment page as a visual for all healthcare practitioners to recognise. This will alert all clinicians of a change of Primary midwife, the date and gestation of the patient and captures the pregnancy information to date. This minimises the risk described in the determination when continuity of care is interrupted. NHSL have agreed a completion date by Summer 2025. National discussions with all health boards and Scottish Government policy leads for Maternal Health are scheduled to take place on 7^th May 2025 to consider any further actions from a national perspective.

Recommendation 4

All health boards that provide maternity services should ensure they have a system to allow a note to be added to a patient’s electronic records in order to highlight a further reason for a referral to a pre-existing appointment with a consultant.

Response

NHS Lanarkshire introduced the antenatal holistic care pathway in 2022 as an interim measure whilst awaiting publication of the maternity pathways of care. The new national maternity pathways of care were launched February 2025 and are subject to local benchmark to understand any extra accommodation and / or resource requirement. The target of transfer to the national pathways is Summer 2025. Badgernet has multiple functionality to enable communication between practitioners. At the moment, the communication and clinical note function can be used to highlight the reason for further referral outwith the core appointments are per Holistic Pathways of care. However, NHSL as part of moving to the new maternity pathways implementation has requested a meeting with System C and National digital midwifery group in order to understand options on how this note can be made mandatory on the risk assessment banner.  This will allow visualisation to all healthcare providers that a further referral has been made outwith a pre existing appointment. Until then, current practice on adding a note will continue and the risk profile of the patient will be updated appropriately based on the outcome of the Consultant assessment. The Primary midwife will be responsible for this referring and reviewing the outcome of any extra referrals.

Recommendation 5

The Electronic Record Keeping Guidance and Audit Tool issued by the Royal College of Midwives should be reviewed to address situations in which midwives may not have access to electronic notes when triaging patients. Guidance should be developed providing that ordinarily, calls from expectant mothers should always be triaged having accessed the patient’s electronic notes. Where that has not been possible, the guidance should provide that midwives should access the notes as soon as possible, complete a note of the communication and review the obstetric history to ensure that the advice dispensed was correct. If the advice requires to change in light of the information contained in the electronic notes, the patient should be contacted with further advice as soon as possible. Healthcare professionals assessing or triaging patients should require to confirm and record on BadgerNet (or similar electronic system) that that they have reviewed and considered the obstetric history before providing advice

Response

All calls in NHS Lanarkshire are now triaged by hospital based midwives in Maternity Triage department as opposed to the system in 2019 where midwives could triage outside a hospital setting.  As a standard, NHS Lanarkshire have a midwife triaging all calls in a quiet space with real time access to electronic patient records using BSOTS algorithms and protocols.  Local learning has shown continuity of telehealth triaging with real time documentation on badgernet notes aides safety and prioritisation of each individual care needs therefore as a principle,  a midwife is always live on badgernet accessing the Electronic Patient Record and information detailed within the EPR as they risk assess on the telephone. The RCM tool is utilised as part of documentation audits to ensure documentation standards which are discussed as part of care assurance.

The last section ‘Healthcare professionals should confirm and record on mandatory electronic records (badgernet) that they have reviews and considered the obstetric history before providing advice.’  This is new practice. An options appraisal has been developed to consider this. The preferred option is to liaise with System C to request a mandatory question is added to the triage call sheet on Badgernet. We are requesting the question ‘Have you reviewed the risk assessment section whilst assessing the patient?’ is incorporated with a mandatory drop down menu that must be answered before the system user can save the record. This is expected to take a minimum 9 months to develop.  In the interim, the Senior Charge Midwife for Triage in tandem with the midwives using the system are looking to codesign a short term solution in which midwives will document, via the BSOTS triage call sheet, confirmation that the records and obstetric history have been reviewed as part of every care episode record.  Expected date of completion is Summer 2025.

.

Recommendation 6

All health boards that provide maternity services should consider acquiring hand held ultrasound scanners to detect the presentation of the fetus when a women reports spontaneous rupture of membranes or attends for induction or augmentation of labour.

Response

NHSL have developed pathways and guidance for midwives on utilisation of hand held scanners with initial testing in outpatient settings where women / birthing people present with Pre labour rupture of membranes. Data evaluation is complete. Learning was garnered which focused on staff education and competency and now forms part of the implementation and spread plan across Maternity services. There are a number of change ideas in the service underway to ensure this practice is implemented safely considering all aspects of care. The Womens service safe care governance group continue to progress this action with completion expected Summer 2025. In addition, we are liaising with other health boards who have implemented to understand any shared learning.

Recommendation 7

System C Healthcare Ltd and all health boards using BadgerNet should consider how the engagement of the presenting part can be better recorded on BadgerNet and specifically, whether an assessment of ballotability should be recorded

Response

As part of documentation of the fetal presentation in Badgernet, the mandatory fields include head engagement. The clinical note cannot be saved without clicking on a drop down list and the clinician selects from the options of fifths palpable.  There is a clinical note section in which practitioners will be able to write in free text if the presenting part is ballotable however better practice would be System C including a mandatory ballotability selection.  Therefore, as part of the meeting and discussions with System C, we are requesting ballotability is included in the EPR as a mandatory field and is included in every antenatal assessment. Whilst we are awaiting this function, the newly appointed Digital Midwife in conjunction with Senior Midwives and Practice Education Facilitators are commencing a programme of practice education for community midwives  which includes documentation of ballotability in the free text box. Via the Lead Midwife Educators steering group, further discussions are required to ensure this area of clinical care is captured in the teaching programme for student midwives who will be taught this in placement. Summer 2025 is the expected roll out of the education programme for all midwives.

Recommendation 8

Each maternity unit which receives emergency admissions in Scotland should introduce a telephone line for sole use by Scottish Ambulance Service crews giving them direct access to maternity units (“a red phone”). Ambulance crews should be provided with a simple means of identifying the correct telephone number for each red phone in each maternity unit in Scotland.

Response

NHS Lanarkshire’s ‘red phone’ was installed 2023 in maternity triage. It is an external phone line for sole use between Scottish Ambulance Service (SAS) and maternity triage. Education and pathway meetings were held with SAS managers and the maternity team to co-create operational definitions for its use.

Recommendation 9

Consideration should be given to the introduction of video facilities to aid communication between paramedics and midwives or obstetricians in emergency situation

Response

We do not use these facilities at the moment and are cognisant of the challenges of so doing. We are seeking national guidance on how we would take this forward in line with information governance, confidentiality, systems and process and working in collaboration with other health boards to understand shared learning and potential for a Once for Scotland approach.

Recommendation 10

Questions posed by healthcare professionals designed to elicit from a patient both a medical or obstetric history and information on current presentation, should make it clear that information related to the present and the past is sought. Health Boards should review pre-populated questions on BadgerNet (or similar systems) to ensure that if they are deigned to elicit information relating to present and past concerns that is clearly stated.

Response

There does not appear to be a function in BadgerNet to enable this recommendation in the way it is intended at the present time. The Risk profile banner displays all risks of previous and current pregnancy however BadgerNet does not enable this function as per recommendation 10 therefore we are scoping options to implement this recommendation. Our preference would be for a national digital solution and therefore NHSL are liaising with System C and all health boards to share ideas and solutions for this recommendation.

Recommendation 11

If “worsening advice” is provided by triaging midwives which includes advice to take analgesia and to call back if symptoms do not improve, women should be provided with an approximate timeframe in which to do so.

Response

BSOTS enables this function. Within the triage call, these are mandatory fields that the midwives must to complete or they cannot progress the advice and completion of the call. During the telephone call, the practitioner is supplied with algorithms and protocols in order to risk asses the patient appropriately.  action of advice which also includes when to call back. BSOTS asks more questions that must be complete as opposed to the typical triage section in BadgerNet used in 2020/21.

Form  6.2

Response

SHERIFFDOM OF SOUTH STRATHCLYDE, DUMFRIES & GALLOWAY AT

GLASGOW

Court ref: GLW-B1011-23

RESPONSE

to the

DETERMINATION OF SHERIFF PRINCIPAL A Y ANWAR KC

[2025] FAI 15

UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016

into the deaths of

LEO LAMONT, ELLIE McCORMICK AND MIRA-BELLE-BOSCH

To: the Scottish Courts and Tribunals Service

1.

Scottish Ambulance Service, being a participant in the inquiry and being an organisation to whom a recommendation under section 26(1)(b) was addressed, do respond to the Court’s eleven recommendations as follows.

Recommendation 1

Greater Glasgow & Clyde Health Board (“GGCHB”) should develop a trigger list or similar system to (a) aid in the identification and assessment of symptoms that might be indicative of preterm labour and (b) inform a decision as to whether a patient should attend for clinical assessment. When a telephone assessment is carried out with a patient presenting with any symptoms of preterm labour, a list of relevant enquiries should appear on BadgerNet, similar to those that appear for conditions such as: term labour; reduced fetal movement; and rupture of membranes. GGCHB should conclude the development of a guideline for preterm labour as soon as possible. Each of these measures should specify a low threshold for attendance for clinical assessment to reflect the low threshold for admission and obstetric intervention recommended by the NICE Guideline on Preterm Labour and Birth, November 2015.

All health boards that provide maternity services should review their practices and guidelines for the identification and management of pre-term labour.

Response

Not applicable

Recommendation 2

All health boards in Scotland that provide maternity services should review the information displayed on electronic maternity records relating to previous preterm births. They should consider the creation of an automatically generated critical alert for previous preterm labour where one does not exist.

Response

Not applicable

Recommendation 3

All health boards in Scotland that provide maternity services should ensure they have a procedure that requires an existing named midwife to create a handover note upon a planned change of named midwife. The handover note should be stored on BadgerNet, or similar electronic records, and should draw attention, in particular, to any prior complications or risk factors in a woman’s pregnancy to ensure that these are not lost sight of if continuity of care is interrupted.

Response

Not applicable

Recommendation 4

All health boards that provide maternity services should ensure they have a system to allow a note to be added to a patient’s electronic records in order to highlight a further reason for a referral to a pre-existing appointment with a consultant.

Response

 Not applicable

Recommendation 5

The Electronic Record Keeping Guidance and Audit Tool issued by the Royal College of Midwives should be reviewed to address situations in which midwives may not have access to electronic notes when triaging patients. Guidance should be developed providing that ordinarily, calls from expectant mothers should always be triaged having accessed the patient’s electronic notes. Where that has not been possible, the guidance should provide that midwives should access the notes as soon as possible, complete a note of the communication and review the obstetric history to ensure that the advice dispensed was correct. If the advice requires to change in light of the information contained in the electronic notes, the patient should be contacted with further advice as soon as possible. Healthcare professionals assessing or triaging patients should require to confirm and record on BadgerNet (or similar electronic system) that that they have reviewed and considered the obstetric history before providing advice

Response

Not applicable

Recommendation 6

All health boards that provide maternity services should consider acquiring hand held ultrasound scanners to detect the presentation of the fetus when a women reports spontaneous rupture of membranes or attends for induction or augmentation of labour.

Response

Not applicable

Recommendation 7

System C Healthcare Ltd and all health boards using BadgerNet should consider how the engagement of the presenting part can be better recorded on BadgerNet and specifically, whether an assessment of ballotability should be recorded

Response

Not applicable

Recommendation 8

Each maternity unit which receives emergency admissions in Scotland should introduce a telephone line for sole use by Scottish Ambulance Service crews giving them direct access to maternity units (“a red phone”). Ambulance crews should be provided with a simple means of identifying the correct telephone number for each red phone in each maternity unit in Scotland.

Response

The Scottish Ambulance Service has been engaging with all territorial Health Boards across NHS Scotland to support the implementation of a dedicated ‘Red Phone’ telephone line in each emergency admission maternity unit, for sole use to communicate directly with Ambulance crews. Access for crews to the appropriate telephone number to contact each maternity unit will be facilitated via the JRCALC clinical guidelines smart phone app, available at all times on Service issued mobile phones provided to all clinical staff.

Recommendation 9

Consideration should be given to the introduction of video facilities to aid communication between paramedics and midwives or obstetricians in emergency situations

Response

The Scottish Ambulance Service continues to engage with maternity leads regarding the resource and infrastructure required for, and the practical use of, remote video consultation facilities to support communication and emergency maternity care provision by Ambulance clinicians in situations that occur outside of emergency admission maternity units.

Recommendation 10

Questions posed by healthcare professionals designed to elicit from a patient both a medical or obstetric history and information on current presentation, should make it clear that information related to the present and the past is sought. Health Boards should review pre-populated questions on BadgerNet (or similar systems) to ensure that if they are deigned to elicit information relating to present and past concerns that is clearly stated.

Response

Not applicable

Recommendation 11

If “worsening advice” is provided by triaging midwives which includes advice to take analgesia and to call back if symptoms do not improve, women should be provided with an approximate timeframe in which to do so.

Response

Not applicable