Bobby was born by emergency Caesarean section at the Lincoln County Hospital following his mother’s admission to the Labour Ward with an abnormal trace at 40 weeks + 6 days. His mother had been experiencing reduced fetal movements. On admission to hospital at 10.20am, a CTG trace was commenced. Despite regular monitoring, a decision to perform a C-section did not take place until 1.20pm, 3 hours after admission; and even then, Bobby was not delivered until 2.11 pm, a further 50 minutes later. When he was born, he had suffered a lack of oxygen to the brain and required respiratory support. Sadly, his condition did not improve and he passed away 2 days later.
The Inquest heard from midwives and doctors involved in Bobby's care as well as independent experts who commented on the treatment received. The Trust accepted that there had been a "very serious failure" in the ante-natal midwifery care, which had caused "shockwaves" to the staff involved. It was accepted that Bobby's mother, Catherine, had been given inappropriate treatment from the outset when her Body Mass Index (BMI) had not been correctly calculated and she had been classified as 'low risk'. There were further missed opportunities in referring Catherine for additional testing and for Consultant led care at later appointments to investigate the possibility of gestational diabetes. Had this taken place, it is likely that Catherine would have been induced between 39-40 weeks, which could have avoided his death.
The failings above were compounded by her treatment at hospital. There had been difficulties in the interpretation of CTG traces used to monitor the baby's heart rate, and it was accepted, when questioned, that in reality, Catherine's was not a low risk pregnancy. Senior review should have been sought earlier which could have led to earlier delivery.
Arti Shah, solicitor for the family, issued the following statement:
"Bobby’s family have been through a devastating experience that could easily have been avoided had appropriate steps been taken to monitor his mother during her pregnancy and at hospital. Not only did she receive substandard ante-natal care on a number of occasions, this was compounded by further failings when she attended hospital, despite regular monitoring. It has been important to hear what lessons have been learned and implemented from this tragic case to prevent it happening again."
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