A baby boy died after suffering a brain haemorrhage in a failed forceps delivery where “excessive force” was used, a coroner’s report says.
Frederick Terry, also known as “Freddie”, died about 40 minutes after he was born under the care of the Mid and South Essex Hospitals Trust on November 16, 2019.
The Trust said it was “deeply sorry for the failings in his care”.
Forceps are curved metal instruments which fit gently around a baby’s head to aid the delivery of the child.
An inquest into Freddie’s death at Broomfield Hospital in Chelmsford was heard in September this year where it was recorded he was stillborn and no further evidence would be called.
However, Senior Coroner Caroline Beasley-Murray has prepared a report to prevent future deaths which she has sent to the trust.
In the report, Mrs Beasley-Murray said: “Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on 16 November 2019 and death was confirmed after 40 minutes of resuscitation attempts.
“The cause of death at post mortem examination has been given as 1a) hypovolaemic shock, 1b) skull fracture and scalp laceration and haemorrhage 1c) birth trauma.
“The evidence showed that baby Freddie’s very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby.”
Mrs Beasley-Murray found 11 matters of concern in her investigation, including:
- A lack of risk assessment leading up to the mother’s delivery .
- The forceps delivery was attempted without recognising an occipito-posterior position.
- The coroner said more training was required and use of scans developed
- The injuries imply an excessive degree of force in the application of the forceps and the traction.
- Concerns about the engagement and induction of locum staff and management of staff levels on the maternity ward.
- The need for a bleep in the neonatal unit.
- Accuracy of record keeping.
- Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre.
- Training and procedures in respect of how communications with the family should be carried out.
- Availability and suitability of resuscitation equipment and procedures on the maternity ward
- The trust’s Action Plan must be rigorously carried out.
The Trust has stated the death of Freddie took place in Broomfield Hospital in Chelmsford, the Echo newspaper reported.
Mrs Beasley-Murray said in her report: “It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery.
“Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth.
“In March 2019, HM Government issued a consultation on coronial investigations of stillbirths.
“It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.”
Diane Sarkar, chief nursing officer for the Trust, said: “Our thoughts and sympathies remain with Frederick’s family and loved ones, and we are deeply sorry for the failings in his care.
“We have been determined to learn from Frederick’s death, and we have strengthened our practices, introduced enhanced staff training, and embedded more robust guidelines to ensure that the quality of care at the Trust continues to improve.”
Basildon Hospital’s maternity unit has been told this year it must improve patient safety after it was branded “inadquate” by the Care Quality Commission earlier this year.
The CQC made an unannounced visit to the unit in September to check its recommendations had been implemented, but it still had “ongoing concerns”.