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  5. Common obstetric problems, intrapartum labour ward
  6. Reporting a perinatal death to the Procurator Fiscal (1010)
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Reporting a perinatal death to the Procurator Fiscal (1010)

Please report any inaccuracies or issues with this guideline using our online form

The Crown Office and Procurator Fiscal Service (COPFS) booklet “Reporting deaths to the Procurator Fiscal: Information and Guidance for Medical Practitioners” provides a clear concise guide to assist medical practitioners to decide whether a death requires to be reported to the Procurator Fiscal and, if so, how to go about doing this.

 

The death of any baby who falls into the following categories should be reported to the Procurator Fiscal:

  • a sudden, unexpected and unexplained perinatal death including deaths where results of investigations which may explain the death are outstanding
  • where the body of a newborn is found
  • where the death may be categorised as a Sudden Unexpected Death in Infancy (SUDI)
  • which arises following a concealed pregnancy
  • stillbirths / neonatal deaths following maternal trauma / assault / domestic abuse
  • unexplained neonatal death including deaths due to hypoxic ischaemic encephalopathy where the cause for this is unknown
  • neonatal death with unexplained collapse / poor condition at birth

Many intrauterine deaths will be unexplained at the time of birth.  If the obstetric team are in any doubt about whether to submit a report (even if investigations are in progress), it is advisable to discuss the death with the Procurator Fiscal in advance of submitting the report as it will depend on the individual circumstances in each case.

Factors which make a stillbirth reportable will include, but are not limited to, the following:

  • where concerns have been expressed
  • the circumstances will be likely to be subject to an Adverse Event Review
  • it is an unexpected or unexplained intrapartum stillbirth

All reportable deaths must be notified to the Procurator Fiscal as soon as possible after occurrence and before any steps are taken to issue a death certificate.

In situations where it is not clear if the perinatal death is reportable, discussion with the Procurator Fiscal should take place as soon after birth as possible.

The need to contact the Procurator Fiscal must be considered before a Post Mortem is discussed with the parents, especially if consent for a PM is not going to be given.

If the obstetric team are unsure what to do in a particular case, Dr Penman (Consultant Paediatric and Perinatal Pathologist) can be contacted for advice via switchboard (out of hours on-call service also provided).

The doctor with the most detailed knowledge of the circumstances of the death should report it.  For a perinatal death, the on-call Obstetric Consultant should be involved in determining who is to do this.

The death can only be reported by a medical practitioner – the doctor may need to discuss the death with the midwife in advance of reporting it to ensure he/ she has a detailed knowledge of the death and is in a position to provide all relevant information and answer any questions that may be asked about the circumstances of death.

The death should be reported to the Scottish Fatalities Investigation Unit (SFIU) team in whose area the significant event leading to the death occurred.

For perinatal deaths which have occurred in NHS Greater Glasgow and Clyde, contact details for the SFIU West team which is based in the Procurator Fiscal’s office in Glasgow are:

SFIU WEST
Telephone: 0300 020 1798
Email: SFIUWest@copfs.gov.uk

In normal circumstances, death reports should be made to the Procurator Fiscal during office hours.  In situations where the death is suspicious, a death report may be made outside office hours to the on-call service, contactable through the police.  This facility should be used in exceptional circumstances only where the matter cannot wait until the next working day.

The reporting doctor should provide the Procurator Fiscal with all of the information required by completing the ‘Notification of Death’ form (ef5 form), a copy of which is contained in Annex 3 of the COPFS guidance (via above link).

An advance call for advice is not a substitute for submitting a completed ef5 if the outcome of the advice call is that the death is reportable to the Procurator Fiscal.

The blank eF5 form will be emailed to you if you do not have access to a copy and should be returned by email to the SFIU West mailbox as soon as possible.

It may be necessary to have a further discussion with the Procurator Fiscal after the eF5 has been received.

The reporting of the death and all discussions with the Procurator Fiscal should be recorded in the mother’s BadgerNet record.

Editorial Information

Last reviewed: 15/03/2022

Next review date: 15/03/2027

Author(s): Jane Richmond.

Version: 1

Approved By: Obstetrics Clinical Governance Group

Document Id: 1010

References

Crown Office & Procurator Fiscal Service (2015). Reporting deaths to the Procurator Fiscal: Information and Guidance for Medical Practitioners (last revised May 2019).