Justice for parents after baby guidance was not followed

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4 minute read

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When a baby dies within four weeks of being born, it’s called a ‘neonatal death’ (also known as ‘newborn death’).

Most deaths usually occur within the first week after birth, and the majority are babies who have been born prematurely. This is because premature babies are sometimes so small that their organs are not yet fully developed and cannot function properly. Premature babies are also at greater risk of developing infections.

Unfortunately, sometimes neonatal death can occur in babies born at full term as a result of complications during or after birth. This was the case for Courtney and Jordan, who sadly lost their son Ollie in 2017.

Courtney and Jordan’s story

Courtney fell pregnant in late 2016. Her pregnancy was going smoothly and both her 12 and 20 week scans and midwife appointments showed nothing of concern, although notes at the time did show concern that there was no GROW chart (used to predict the growth and size of the baby) in her medical records.

A scan when she was 37 weeks pregnant didn’t show anything concerning.

Two weeks later Courtney was admitted with a suspected rupture of membranes. A community midwife appointment was arranged for her the following week. At this appointment (and now 40 weeks pregnant) Courtney was given a cervical sweep. It was again noted that there was still no GROW chart in her records.

Courtney had another scan at 41 weeks. A senior review took place and it was decided that Courtney should be booked for an induction of labour as the baby was considered “Small for Gestational Age” (which describes babies who are smaller than usual for the number of weeks of pregnancy). These babies require special monitoring, and the Trust treating Courtney had specific guidance for any staff treating someone carrying a baby that met the criteria.

As planned, Courtney was admitted the next day for the induction. When she was admitted, at 12:30pm, everything was noted as being normal. The baby’s movements were felt, her membranes were intact and she was not suffering from any vaginal bleeding.

At 1:40pm a pessary was inserted to help induce labour.

Over the next few hours Courtney had painful contractions, which she reported as being constant. Cardiotocography (CTG), which is used during pregnancy to monitor fetal heart rate and uterine contractions, was stopped at 4:50pm. At this time the results were reported as ‘reassuring’.

Courtney was then not observed for over two and half hours, until 7:25pm when she reported that she was having regular pains.

A second CTG was then started shortly after 8pm. At 8:40pm, after a changeover of staff, the CTG was noted as being ‘pathological’ (potentially indicating the baby was in distress). The pessary was  removed. Ten minutes later the baby’s heart rate had dropped even further and was not recovering. Courtney was transferred to the delivery suite, but by 9pm the baby’s heart rate had dropped even further.

A ventouse delivery (delivery using an instrument which uses suction to attach a cup onto the baby’s head) was attempted but this was unsuccessful. An episiotomy was performed (a surgical cut made in the perineum to make delivery easier) and at 21:10 Courtney’s son Ollie was born with the use of forceps.

Ollie was born with his cord around his neck and no heartbeat was detected. He was intubated and taken to the neonatal unit 40 minutes after being born.

The following day an EEG and an ultrasound scan of Ollie’s brain showed changes in keeping with brain damage caused by oxygen deprivation. Ollie was diagnosed with severe brain damage and multi-organ failure.

The Hospital explained to Courtney and Jordan that the damage Ollie had suffered was permanent and that there was nothing more they could do for him. His parents made the heart-breaking decision to withdraw Ollie’s life support and he passed away at just one day old.

The Hospital Trust carried out an investigation into Ollie’s death, and prepared a ‘Root Cause Analysis Investigation Report’. In the report the Trust admitted that, amongst other things, ward staff did not follow Trust guidance for the care of a woman with a (predicted) ‘Small for Gestational Age’ baby and that CTG monitoring, vaginal examination, removal of the pessary and timely decision making was delayed.

After Ollie’s death, his parents Courtney and Jordan both suffered with depression, anxiety, flashbacks and post-traumatic stress disorder (PTSD); for which they required medication and counselling.

How we helped

They approached Enable Law in 2018 to explore the possibility of making a claim against the Trust in relation to Ollie’s death.

Both Courtney and Jordan both brought claims against the hospital.

As she suffered a psychiatric injury after being directly involved in an incident of clinical negligence, Courtney brought what is legally known as a “primary victim claim”.

Jordan then brought what is known as a “secondary victim claim”, because he suffered a psychiatric injury after witnessing the events and the distress that Courtney and Ollie went through.

Advice was sought from independent medical experts on whether Ollie should have been delivered earlier, and whether this would have avoided his death. The experts agreed that, had Courtney been properly monitored, then Ollie would have been delivered by 8:55pm (15 minutes earlier).

They also agreed that, had this happened, he would have survived.

These allegations were subsequently admitted by the Trust, and they agreed to pay £62,500 in compensation.

Although the Trust did not admit they were liable for Jordan’s claim as a secondary victim, Jordan was able to receive some compensation as part of the overall settlement.

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