Inadequate obstetric emergency training for paramedics
Association of Ambulance Chief Executives received 2 coroners' reports about this hazard between 11 May 2016 and 16 Sept 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from Association of Ambulance Chief Executives was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“This is a clear training issue, and may well apply nationally.”
Original on judiciary.uk ↗ No published response from Association of Ambulance Chief Executives was found for this report.
- 9 years 4 months laterClosely relatedConfidence 0.90 · higha different coroner
“absence of any mandatory training on obstetric emergencies was putting lives at risk.”
Original on judiciary.uk ↗ Association of Ambulance Chief Executives responded, stating 1 specific action.Response (PDF) ↗
“We have received feedback through our networks that since we issued the revised guidance it is helpful and that it has been used to support the delivery of breech babies.”
Stated timescale: September 2023
- All reports to Association of Ambulance Chief Executives
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2016 → 2025Mohammed Khan9 years 4 months after Mia Gibson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient training for paramedics on managing obstetric emergencies. The earlier report notes a clear training issue, while the later report states the absence of mandatory training puts lives at risk.
Mia Gibson · 11 May 2016
“This is a clear training issue, and may well apply nationally.”
Original on judiciary.uk ↗ Mohammed Khan · 16 Sept 2025
“absence of any mandatory training on obstetric emergencies was putting lives at risk.”
Original on judiciary.uk ↗
No published response from Association of Ambulance Chief Executives was found for this report.
Stated action · timescale: September 2023
“We have received feedback through our networks that since we issued the revised guidance it is helpful and that it has been used to support the delivery of breech babies.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Association of Ambulance Chief Executives at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2016 → 2025 | 0.67 | 0.31 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.