Recurance · prevention of future deaths reports
Pre-inquest brief
Inaccurate and incomplete clinical records
The earlier warning
Frederick Terry · 9 Sept 2020 · Caroline Beasley-Murray, Essex
“Accuracy of record keeping - Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre”
judiciary.uk/prevention-of-future-death-reports/frederick-terry
What was promised
Stated action 1 · response to Frederick Terry (9 Sept 2020) · stated timescale: none stated
“The guidelines have been updated to reflect the Royal College of Obstetricians and Gynaecologists recent guideline on Assisted Vaginal Birth (April, 2020)1, this includes a risk assessment to assist with decision making for an assisted vaginal birth, an improved documentation pro forma following an assisted vaginal birth and reference to ensuring that the baby's head is checked immediately at birth for signs of trauma when obstetric instruments have been applied.”
judiciary.uk/…/2020-0173-Response-from-Mid-and-South-Essex-Foun…
What recurred
- 20 Jul 2026 · Margaret Templeman · Rebecca Mundy · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Frederick Terry · 9 Sept 2020
“Accuracy of record keeping - Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre”
Later · Margaret Templeman · 20 Jul 2026
“During the course of this investigation I heard evidence of significant deficiencies in the maintenance of clinical records relating to hydration, nutrition, communication, observations, medication management and aspects of clinical decision making.”
What happened next
No web check of the stated actions has been published for this chain.