Arti was instructed to investigate a claim into Sebastian's death following a delay in delivery. The hospital's own internal investigation concluded that it had provided "sub-optimal care" and, critically, that different management could have made a difference to the outcome. The Coroner opened an Inquest into Sebastian's death.
The Trust failed to respond to our invitation for early admission of liability to reduce the costs, so Arti obtained expert evidence from a midwife, obstetrician, neonatologist and paediatric neurologist to deal with breach of duty and causation. All four experts agreed that there had been shortcomings in care.
A crucial section of the CTG records, available for the purposes of the investigation, went missing at the time of disclosure. This was acknowledged by the Trust. Further, there were concerns regarding:
- The repeated administration of Syntocinon without consent, a drug used to speed up labour
- The failure to listen to Sebastian's mother's repeated requests for a Caesarean section
Arti represented the family at an Inquest in February 2017. The Coroner delivered a narrative verdict, commenting that Sebastian "should have been delivered earlier, and if he had been, it is likely that he would have avoided the final period of severe hypoxia…….In those circumstances, it is likely that he would have been born healthy". The Coroner also concluded that it was this brain injury that made him susceptible to infection that caused his death.
Despite this, no admission of liability was received for a further five months and the family has never received an apology. A low offer of settlement was made but in January 2018, Arti served a comprehensive schedule of loss and the case was finally settled in April for almost double the original offer.
In March 2017 NHS England published National Guidance on Learning from Deaths. It recognised that there was a "variation" in dealing with "unexpected" deaths, including how this is defined, when investigations are triggered, and how they are reviewed at internal meetings and further communicated to bereaved parents.
"Sadly, this seems to be the norm in my experience – I have been instructed in 3 similar cases following Sebastian's death, including a further case at Nottingham City Hospital. It is worrying that lessons are not being learned, and earlier admissions and apologies are not offered, which could make all the difference in alleviating parents' grief."
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