The Trust’s own root cause analysis identified multiple problems in the hours before the baby’s birth, in the delivery and then in the treatment she received once she was born.
A subsequent external independent review identified major suboptimal care in Midwifery and Obstetric care (both registrar and consultant level) and in Paediatric care (both registrar and consultant level) including failures in the resuscitation and stabilisation attempts and delays in referral to a tertiary centre. The review identified that most of these failures were individually “almost certainly relevant” to this baby’s death.
At a three-day inquest in May 2017, the coroner also concluded that delays in AF's delivery, misclassification of the CTG trace, delays in intubation after delivery and delays in seeking help from tertiary services each caused or contributed to the death. Other serious problems with the hospital's care were also considered significant but unlikely to be causative. AF's mother, an NHS nurse, could not bear to attend much of the inquest.
The Trust has since apologised and its transparency about failings in accordance with duty of candour was recognised. Despite the terrible circumstances of this case, the family and clinicians have kept open their lines of communication, even at the inquest. The family want no other mother or baby to have to endure similar failures.
Following the inquest, Iona represented AF's mother in a clinical negligence claim for psychiatric injury and losses incurred as a result of the negligence. This resulted in interim payment which allowed her to embark on IVF. The case subsequently settled at mediation prior to issue of proceedings.
Following settlement, the family said:
"Despite the process being remarkably difficult and upsetting, your professional and supportive approach helped us to feel reassured…You are clearly experts in your field and ensured that all appropriate issues were raised, addressed and understood by us both. We would highly recommend you to anyone seeking legal representation."
Image credit: By Dormskirk [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], from Wikimedia Commons
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