Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026).

I am Emma Brown HM Area Coroner for the coroner area of Birmingham and Solihull

27 July 2026

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

1.National Institute for Health and Care Excellence   
2.The Royal College of Obstetricians and Gynaecologists   
3.   
4. 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 21 September 2026. I, the coroner, may extend the period if an appropriate application is  made. 

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 a duty to send a copy of your response to the Chief Coroner.   In accordance with the Chief Coroner’s Publication Policy, you should send me any  representations regarding the publication of your response. These representations should be  made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision.   Please note any links to webpages included in the response will not be checked for sensitive  information prior to publication, as the information is already online.   The names of those who do not respond to PFD reports are regularly published on the Chief  Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary. 

The evidence in this investigation identified that there is a risk to life arising from the absence of specific national guidance for intrapartum care professionals identifying that 1) a period of loss  of contact on a continuous CTG trace can be due to acute fetal bradycardia, distress or demise  and b) a specific period after which loss of contact, despite actions to improve contact, should  be escalated as an emergency or, at least, considered for escalation. 

 In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.

On 27 April 2026, I commenced an investigation into the death of Amelia Nasiadka, aged 68  hours    

The medical cause of death was   

1a Hypoxic-ischaemic encephalopathy      
1b       
[Text Wrapping Break]
1c   
[Text Wrapping Break]
1d      
II             

How, when and where – see below 
[Text Wrapping Break] 

Conclusion    

The investigation concluded at the end of the inquest.   

The conclusion of the inquest was: “Death was a result of oxygen deprivation caused by a  delayed delivery arising from prolonged and repeated failures in CTG monitoring, assessment and escalation.”     

[Please explain the relevant circumstances of the individual’s death, ideally this should be in no more than 500 words]     

Amelia died at Birmingham Heartlands Hospital on the 24th September 2025 due to a  catastrophic brain injury resulting from lack of oxygen during her delivery at Birmingham   

Heartlands Hospital on the 21st September 2025. Amelia’s mother had been admitted to the  delivery suite shortly after 2am on the 21st September 2025 in active first stage labour. She  required constant CTG monitoring due to her high-risk status. A continuous CTG was in place  from 02:30. The CTG trace started showing abnormalities, including periods of loss of contact,  after 03:04. It should have been identified from 03:30 onwards that the situation required  emergency escalation which would have been likely to result in delivery by 04:30. However,  escalation did not take place and whilst some efforts were made to improve contact and at  times a trace returned it never reached an interpretable level and the delay in escalation and  delivery continued. Ameilia was eventually delivered by a ventouse instrumental delivery at  05:41.     

The MATTERS OF CONCERN are as follows:     
[250-word statement addressing what circumstances of the death have led to the coroner’s    concern, and why the coroner thinks the person to whom the report is directed is responsible for taking action to prevent future deaths. This statement must not propose what action should be  taken, as coroners cannot make recommendations].   

On 21st September 2025 the University Hospitals of Birmingham NHS Foundation Trust had a  local guidance on fetal monitoring that included a section on loss of contacting highlighting that,  amongst other things, loss of contact could be due to acute fetal bradycardia or demise and that after allowing a timeframe of 3 minutes to relocate the fetal heart rate (‘FHR’) if unable to do so,  assume potential fetal bradycardia and commence emergency procedures. The Trust had  introduced this guidance due to common themes relating to lack of oversight of potential acute  causes of loss of FHR contact during constant fetal monitoring. The 3-minute period derived  from the “3, 6, 9, 12” emergency obstetric training mnemonic for ensuring rapid escalation and  timely delivery.   

In Amelia’s case between 03:02 and delivery there were several periods where contact was lost  for over 3 minutes, including one of 21 minutes, without emergency escalation. The Trust  guidance was not known to 3 of the practitioners involved (a band 6 midwife, a band 7 midwife  and a specialist trainee 4), 2 of whom had only recently started working at the Trust. Evidence  was that the absence of similar guidance in NG22 hampered awareness. The evidence was that this local policy is not reflected at all other maternity units nationally.   

Whilst action has occurred and is ongoing to raise awareness of the Trust guidance this is not a  local issue and life is at risk if maternity practitioners are not aware of the need to escalate  promptly when the FHR remains undetected after a reasonable period of action to relocate it. It  is my belief that you are able to raise awareness. 

I have a duty to send a copy of my report to every interested person who in my opinion should   receive it.     

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

I can confirm I have sent the report to: (please do not use individual’s names, but instead  roles/titles)     

1.The parents of Amelia     
2.The University Hospitals of Birmingham NHS Foundation Trust  [Text Wrapping Break]
3. The MNSI     
4. The nursing and midwifery council   

I also have a duty to send a copy of the report to the Chief Coroner.     

You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be  sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional  information relating to the publication of  reports and responses.