Neonatal death contributed to by Neglect
Before HM Senior Mrs Caroline Beasley-Murray, Essex Coroner’s Court. Narrative conclusion handed down on 30 July 2019.
Rory Badenoch, instructed by Hugh James Solicitors, represented the family of the Deceased, Ennis Pecaku, at a 3-day inquest into the circumstances of his death from perinatal asphyxia at Basildon Hospital. The Coroner concluded that there were serious failings in the care provided to baby Ennis and to his mother by Basildon Hospital and that his death was contributed to by neglect.
In the later stages of pregnancy, it was confirmed that baby Ennis was in breech position. On 17 September 2018, External Cephalic Version was attempted to change his position within the womb. However this proved unsuccessful and his mother, LD, was booked in for an elective caesarean section due to breech presentation on 26 September 2018.
On 26 September 2018 LD attended Basildon Hospital [“the Hospital”] for elective caesarean section alongside three other women. However, due to a lack of bed space on the maternity unit only one of the four scheduled elective c-sections went ahead as planned. LD was re booked for an elective c-section six days later on 2 October 2018 at which point she would have been 40+2 gestation. The expectation of the treating clinicians was that if she went into labour in the interim period she would be invited to attend hospital immediately and would be offered an urgent/emergency c-section.
Shortly before 4pm the following day [27/9/18] LD contacted the Maternity Assessment Centre [“MAC”] at the Hospital and explained that she was having contractions, had had “the show”, was breech presentation and was slightly panicked as she had had an elective c-section cancelled the previous day that had been re-booked for 2/10/18. She was told to keep monitoring the contractions and to phone in if there was any further development. She was not told to attend the Hospital.
No record was made of the contents of this call nor was it conveyed to midwifery staff on the unit. When questioned on this issue during the inquest the clinicians involved and the independent expert stated that the correct response to this information would have been to invite LD to attend the hospital straight away.
LD called again at 1726 and explained that: she had been contracting approximately every 30 minutes for the last 1 ½ hours; she believed her waters had broken at approximately 1715; she had had a previous labour that had lasted for approximately 4 hours; she was breech presentation; she had had an elective c-section cancelled the day before; and that the c-section had been re-booked for 2/10/18. All of this information was recorded on a “Telephone Advice sheet” on which it was noted that LD was “High risk”. She was told to attend the Hospital and that if she arrived on or after 1800 to go straight to the Delivery Suite as MAC would be closing at 1800.
LD arrived at the Delivery Suite at approximately 1800. The telephone advice sheet from her telephone call at 1724 had not been provided to the Sister in charge of the ward who was not aware of her history or her impeding arrival. Furthermore the Sister in charge of the Delivery Suite was not informed that MAC was due to close at 1800. In the event LD was met by a Midwifery Care Assistant [“MCA”] who informed her that the Delivery Suite was full and redirected her to MAC for assessment.
In evidence the midwives on MAC stated that they were not informed by the Delivery Suite of LD’s impending arrival or the need for assessment. At approximately 1805 she arrived at MAC and provided a urine sample and her sanitary pad to an MCA. The sanitary pad was placed in a sluice for inspection by a qualified midwife.
In the event the sanitary pad was not examined by a midwife on the unit until 1845. The midwives on MAC were not aware of the telephone advice sheet completed at 1724 or the information contained therein, and were not made aware of LD’s presence on the unit until approximately 1842.
At 1845 one of the midwives observed that the sanitary pad provided was meconium stained, and identified that MAC was not the appropriate place for LD (a high-risk patient) to be assessed. Attempts were made to transfer her to the Delivery Suite but the midwife was informed that the suite was full and that she could not be accepted. Accordingly LD was reviewed in a side room in MAC at approximately 1900 [one hour after she had arrived] and preparations for an emergency c-section were commenced.
Throughout this time the three obstetricians on duty [SHO, Registrar and Consultant] were all in theatre. The on-call consultant for the night shift [who did not attend for handover at the start of her shift at 1800] was contacted via telephone at around1830 by the Sister in charge of the Delivery Suite and advised the Sister variously that LD needed to be reviewed by a Registrar, and that a review should take place immediately as LD “might need surgery”, and if there were any concerns to call her back. The Sister in charge of the Delivery Suite stated that the on-call consultant advised her that LD be reviewed by the Registrar once the Registrar had finished in theatre.
In the event the on-call consultant received no further call about LD’s condition, and the Registrar did not attend LD until 1930 [having come out of theatre a few minutes earlier] – at which point, with LD in advanced labour, it was deemed too late to undertake an emergency c-section and Ennis was delivered vaginally. Ennis was born in very poor condition at 1939. Resuscitation attempts were initially successful. However it was clear that Ennis was severely compromised and was unlikely to survive. Ennis died at 2am on 28 September at one day old.
The Coroner instructed Dr Malcolm Griffiths, Consultant Obstetrician, to provide an expert report.
Dr Griffiths opined that Ennis suffered a complete cord occlusion due to cord compression [a recognised risk of a vaginal breech birth] in advanced labour some-time after 19.16 and before he was born at 19.40. This caused an acute hypoxic-ischaemic event. Despite extensive resuscitation his prognosis remained appalling and a few hours after birth he was switched to support care and passed away by 02.00 on 28th September 2018.
Dr Griffiths concluded “there were a series of missed opportunities to have delivered [baby Ennis] sooner by Caesarean Section…”.
In oral evidence Dr Griffiths confirmed that LD should have been invited to attend hospital immediately when she contacted the hospital at 4pm. On arrival at approximately 4.30 pm, given her high level of risk due to breech presentation and relevant past medical history including a cancelled elective c-section the previous day, she should have been reviewed as a matter of urgency. In these circumstances his expectation would be that arrangements would be made to deliver Ennis by urgent c-section as soon as practicably possible and probably within an hour of review. The arrangements for urgent c-section would likely have been expedited when LD’s waters broke at approximately 17.15.
Whilst he could not comment on issues of staffing, capacity and the unit’s ability to open up the second theatre (which was available) following LD’s arrival at 6pm, his expectation in a case involving a high-risk patient in labour, would be that an urgent c-section could be arranged and carried out within one hour. His expectation was also that the on-call consultant would be on site for the evening handover at 6pm [i.e. when Ennis’ mother arrived].
Regarding the causative effect of the missed opportunities Dr Griffiths stated that “if Ennis had been born by any means (vaginal or Caesarean Section) before 19:16 or some time soon after, he would have been born in good condition and would have survived”. He added in oral evidence that Ennis would probably have survived had he been born at any time prior to 19:36.
Mrs Caroline Beasley-Murray gave a narrative conclusion in which she stated “There were serious failings in the care provided to baby Ennis and to his mother by Basildon Hospital. More timely intervention would probably have resulted in a better outcome. Baby Ennis would probably have survived if he had been born at any time before 19.16 on 27 September. Baby Ennis’s death was contributed to by neglect.”
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