Failure to recognise the need for an urgent delivery of a baby girl due to pathological CTG results in results in oxygen deprivation and cerebral palsy - Kingston Hospital | Fieldfisher
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Case Study

Failure to recognise the need for an urgent delivery of a baby girl due to pathological CTG results in results in oxygen deprivation and cerebral palsy - Kingston Hospital

In January 2012, Sarah, pregnant with her first child, went into labour at 40 weeks and 3 days of pregnancy. She was admitted to her local hospital where observations were normal.

However, following continuous CTG monitoring there were increasing decelerations, no FHR baseline and reduced variability; all signs that the baby was becoming stressed. The FHR continued to drop and was slow to recover. An episiotomy to assist with the delivery was discussed but not performed. When baby Lucy was delivered, the umbilical cord was wrapped twice around her neck. Her head was blue and she was noted to be “pale and floppy” and in a “poor condition”. She did not cry.

After delivery one of the midwives asked whether the Sarah wished to hold Lucy. Sarah said yes and after the TENS wires were disentangled, she held Lucy skin to skin. One of the midwives clamped the umbilical cord and Lucy's husband then cut it.

Approximately 3-4 minutes after the delivery the midwives started to try and resuscitate Lucy with mask inflation breaths and pressed the emergency buzzer. The paediatric team arrived one minute later and Lucy's HR was only 60bpm. It then took approximately five further minutes of resuscitation before the Lucy's heart rate recovered to over 100bpm.

A blood gas sample taken at 21 minutes after delivery showed a profound metabolic acidosis. Lucy was subsequently diagnosed with severe hypoxic ischaemia of the brain, resulting in cerebral palsy.

Unbearably, shortly after birth Lucy was also diagnosed with retinoblastoma (a rare form of eye cancer, unrelated to the hospital's negligence) and she died age two years and 10 months.

Kingston Hospital NHS Trust accepted that in relation to the labour and Lucy's delivery that there was a negligent failure to recognise the urgent need to deliver her in view of the pathological CTG and that if the episiotomy had been performed when indicated Lucy would have been spared 17 minutes of profound circulatory insufficiency. However, the Trust did not accept there had been a delay in resuscitating Lucy and that avoiding the 17 minutes of profound circulatory insufficiency would have meant Lucy would have been neurologically undamaged. This was strongly refuted by the neonatologist and neuroradiologist instructed on Sarah's behalf.

The hypoxic ischaemic encephalopathy severely affected all aspects of Lucy's short life and resulted in her requiring significant levels of constant care.

She was unable to swallow and was connected to a feeding tube and pump for 20 hours a day. She also had severe reflux problems. This, in combination with cerebral irritation from the brain injury, led to prolonged, almost constant screaming and distress. It also meant she vomited frequently (10-30 times a day). After a jejunostomy, Lucy's screaming and the vomiting reduced but were still present.  She had to take numerous medications 4-6 times each day for her reflux issues and the pH of her stomach had to be tested each time she was given medication.

Due to her cerebral palsy Lucy was in constant discomfort, and had to be carried for substantial portions of the day. She had regular painful dystonic spasms, for which she required physiotherapy and hydrotherapy and she had occasional seizures. The brain injury also meant that she could only sleep for very short periods at a time, and resulted in developmental difficulties.

Notwithstanding voluntary disclosure of causation evidence and attempts to settle the claim, we were forced to issue proceedings against the Trust. It served a Defence which did not accept all the allegations but accepted that its negligence contributed to Lucy's condition and birth and the injury she sustained.

Sarah and her husband wanted an acknowledgement of the Trust's failings and the injury they caused Lucy. Following negotiations this was achieved when Sarah accepted the sum of £80,000 in respect of the harm caused to Lucy and the additional care that her and her husband gave to Lucy during her short life.

Contact us

For further information about cerebral palsy claims and medical negligence claims, please call Jane Weakley on 03304606773 or email


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