Patient Safety Alerts
See all patient safety alerts on the RCOG website
Patient Safety Alerts are issued by NHS England when systemic actions can be taken to prevent or reduce errors of omission or commission by healthcare staff.
The National Patient Safety Alerting Committee (NaPSAC) has been established to improve the effectiveness of these safety critical communications and to support providers to better implement the required actions.
The key way NaPSAC is doing this is through the introduction of National Patient Safety Alerts.
Alerts relevant to the O&G Members
- Use of Sodium Valproate in Pregnancy
- Safety messaging regarding the use of plastic cord clamps at caesarean section (29 September 2020)
- British Menopause Society update on HRT supply shortages (23 August 2019)
- View all RCOG Patient Safety Alerts under Browse all guidance
Prevention of Future Deaths Reports (Regulation 28)
After an inquest, the Coroner can write a ‘Prevention of Future Death’ or ‘Regulation 28’ report. This happens especially where the Coroner has heard evidence that further avoidable deaths could happen if preventative action is not taken.
Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. They have to respond to these within 56 days showing how they have made changes according to the Coroner’s recommendations, or how they intend to.
All Prevention of Future Death reports and responses are sent to the Chief Coroner and are usually published on the Judiciary website.
RCOG responses to Regulation 28 reports
- View the RCOG's response to Prevention of Future Deaths following Amniocentesis – 2017 (PDF)
- 2015- 0177 Death of Baby Olsberg (PDF)
- 2017-0005-Death of Ana Geanina Sirghi-Marin 2017 (PDF)
- 2017-0054 Death of Maxim Karpovich (PDF)
- 2017-0061 Death of Billy Wilson (PDF)
- 2020-0129 Death of Julie O’Connor (PDF)
- 2020-0206 Death of Baby Noah Richard Poole (PDF)
- 2021-0418 Death of Hurrun Maksur 2021 (PDF)
- 2023-0277 Death of Baby Finlay Austin May
- 2023-0338 Death of Kimberley Sampson and Samantha Mulcahy