During the birth of her first child, Sebastian, in 2012, Tracey was told by the obstetrician that because she had a narrow pubic arch, she should deliver by caesarean section if she decided to have another baby. Unfortunately, the Obstetrician failed to note this significant finding in Tracey's medical records. If she had, Kristian may well have survived.
Throughout Tracey's pregnancy with Kristian, Tracey frequently told doctors and midwives that she had been advised to deliver by caesarean section, but doctors ignored her concerns.
Ms Taylor said "I lost count of the number of times I voiced my fears to doctors about giving birth naturally based on the very real experience of my first labour. Although the doctor then told me about the dangers of my narrow birth canal, because she didn't write anything in my notes, during Kristian's delivery the doctors basically ignored me."
During Kristian's delivery, obstetricians identified an abnormal CTG trace indicative of fetal distress.
Tracey was taken to theatre where an attempt was made to deliver Kristian using a ventouse. After three pulls, the obstetricians were unable to deliver the baby. It was then decided to use forceps. After two pulls, Kristian was still not born. Eventually, Kristian had to be delivered by caesarean section; 1 hour and 39 minutes after the decision to deliver him had been made.
Kristian was born in a very poor condition and he was immediately transferred to University College Hospital for emergency cooling treatment. An MRI scan showed very severe brain damage as a result of being starved of oxygen. His parents were advised to turn off his ventilator and Kristian died in the early hours of 3rd July 2015.
Tracey Taylor said: "After the birth, the doctors did come to see me but seemed not to know what to say except for 'sorry'. They also chose that moment to tell me I wouldn't be able to have any more children naturally."
An inquest into the death of Kristian Jawroski took place at Barnet Coroner's Court before HM Coroner Andrew Walker in March 2016.
The Coroner found that there was a very serious failure by the obstetrician delivering Sebastian in 2012 not to write her findings and advice in Miss Taylor's medical notes. The Coroner went on to say:-
"Had entries been made into the medical notes it is likely that there would have been a caesarean section delivery [for Kristian] and it is likely that the asphyxia as a consequence of prolonged and extended instrumental delivery would not have occurred."
In addition, the Coroner found that "there was a failure to recognise that the instrumental delivery should have stopped and this was a very serious failure" The obstetric team's attempt at a fifth pull with forceps amounted to a "very serious failure to provide basic medical care".
The Coroner said there was an opportunity to render care which if taken would have prevented the death in the sense that Kristian would not have died when he did.
During the inquest it was heard that there is a presumption in favour of vaginal delivery which is partly based on costs to the NHS, which needs to be rebutted in order to be offered an elective caesarean section. The Coroner has written to the Department of Health to address this issue.
We are pursuing a clinical negligence claim on behalf of the Kristian and the Trust has admitted liability in this respect.
Paul McNeil, Head of Medical Negligence Claims at Fieldfisher said:
"A core duty of an obstetrician is to record the specific circumstances of delivery so as to prevent harm to mothers and their babies in future pregnancies. Shockingly, the crucial finding of Tracey's narrow pubic arch during Sebastian's birth in 2012 was not recorded in her notes. It should have been highlighted in neon lights.
"This mistake was compounded when the professionals caring for Tracey during her 2nd pregnancy failed to listen when she repeatedly asked for a Caesarean before her labour began on basis of the advice she had been given immediately after the birth of Sebastian. The inevitable happened. During the botched birth of Kristian he was unable to be delivered vaginally notwithstanding the negligently delayed and crude attempts by the obstetricians. The death of Kristian following a Caesarean and the ensuing family tragedy would have been avoided if the doctors had performed 2 simple tasks- written adequate notes in 2012 and listened to Tracey in 2015."
The clients said:
"The events surrounding the birth of our beautiful little boy have left us utterly devastated. Our faith was solely in those responsible for looking after myself and our little boy and we feel completely let down.
"Kristian should be here, he should've met his big brother and we should've been watching him grow, we should've been watching them grow together. Instead we all mourn the fact that he isn't and never will be."
The case was featured in the Sunday Times "Safer Birth" campaign in April 2016.
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