Claim for the avoidable death of young baby due to failure to monitor his mother correctly

We have recently represented the parents of a baby who tragically died at Kettering General Hospital when he was eight days old.

His mother was induced when she was 12 days overdue and initial CTG monitoring of the baby’s heart rate was satisfactory. She was therefore released for intermittent monitoring. Around three hours later, maternal and fetal observations were performed and the mother started having mild, irregular contractions. These gradually became stronger and so a midwife was alerted. The patient underlined that she had previously had two quick labours, as well as a post-partum haemorrhage. The midwife advised that she did not want to remove the induction propess as she did not want to interfere with the progression of labour. 

Around 40 minutes later, the mother called the midwife again asking for pain relief as her contractions were getting stronger. She was advised to have a bath and keep walking. 

The mother experienced an urge to push some 20 minutes later and was found to be 5-6 cm dilated. It took a further 15 minutes for the baby’s heart rate to be checked, which was found to be very low (bradycardic) at 80 beats per minute. Preparations were therefore begun for the mother’s transfer to the delivery suite but a decision was ultimately made not to move her. The emergency call bell was rung around 2 minutes later and the obstetrician was bleeped 3 minutes later. The baby was ultimately delivered 15 minutes after the bradycardia was identified.  He was in a poor condition and was transferred for cooling. Eight days later he died from severe hypoxic ischaemic encephalopathy (severe brain injury caused by deprivation of oxygen in labour).

An independent review highlighted a catalogue of errors in the care he received, as follows:

• failure to follow the trust’s own induction of labour guidelines;
• failure to commence CTG monitoring when the mother reported three contractions every 10 minutes;
• failure to remove the induction propess when the mother reported these contractions;
• failure to check the baby’s heart rate once the mother reported an urge to push;
• delay in checking the baby’s heart rate after performing the internal examination;
• lack of understanding  from the staff on duty of the time critical nature of bradycardia;
• failure to commence CTG monitoring once the bradycardia was identified.

We sought expert evidence from midwives and neonatologists and this indicated that, with the correct care, the baby would have been born considerably earlier. If this had been the case, he would have survived.

We presented a claim on behalf of the baby’s estate and on behalf of his parents for bereavement damages as well as for the psychiatric injuries suffered by both his mother and his father. We achieved an apology from Kettering General Hospital NHS Foundation Trust and a compensation award for the parents.

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