A midwife tragically lost her baby 17 hours after he was born at the hospital where she works as maternity staff 'did not act urgently enough or escalate care appropriately', a coroner has ruled. Gemma Bentley and her husband Philip, who live with their three children, were left heartbroken when their son Luca died shortly after birth at Burnley General Teaching Hospital in June 2020.
A health care safety panel concluded that a lack of urgency, miscommunication and incorrect classification of foetal monitoring all contributed towards the child's death, the Manchester Evening News reports. The inquest also heard that Mrs Bentley's care throughout her pregnancy had been of the expected standard until June 13 2020 when she was admitted to hospital following scan results which implied her baby's growth had slowed down.
The coroner heard that several delays meant that when Luca's heart rate along with other vital signs showed he was in distress, he was not delivered as soon as he should have been. There was a shocking gap of around six hours between foetal heartbeat monitoring being carried out with a cardiotocograph at around 4:29am on June 13 when the results were normal ad 10:28am that morning when the results were now being raised as an issue.
An inquest at Blackburn Town Hall heard that during this time Mrs Bentley should have been rushed to theatre for an emergency caesarean section as it was uncertain how long little Luca's condition had been deteriorating. Due to the staff's failure to recognise and communicate the severity of the situation a transfer to the birthing suite, which should have only taken a few minutes took 39 minutes and it was another hour before the child was delivered.
Staff attempted to resuscitate him at the neonatal intensive care unit but he was sadly pronounced dead 17 hours after he was born. It was also revealed that Mrs Bentley who has returned to work at the hospital was not made aware of the seriousness of Luca's condition and the urgency of the situation.
Martin Maher, lead obstetrician at the East Lancashire Hospitals NHS Trust, said it was likely due to 'unconscious bias' as Mrs Bentley knew and worked alongside those who were treating her. When asked if it was more likely than not that Luca would have survived if different action had been taken, Mr Maher replied: 'Yes'.
Mr Maher regrettably confirmed that, as the on-call obstetric consultant when Mrs Bentley was admitted, he should have been made aware of the concerns about Luca's condition. The consultant added: "I was concerned that things hadn't been escalated to me. In the immediate aftermath the department was shook that Gemma had lost her baby. This is the last thing we would want especially for a staff member."
The child's death was also not immediately reported to the coroner but Mr Maher explained this was down to the obstetrics and neonatal teams not working 'in a joined-up way'. He added: "All neonatal deaths are now reported to the medical examiner and to the coroner".
Luca's death was attributed to hypoxic ischemic encephalopathy and was referred to the Healthcare Safety Investigation Branch (HSIB) which carried out an independent review of Mrs Bentley's care. The inquest also heard that NHS Resolution which deals with compensation payments to patients agreed with the findings of the HSIB report and said that 'the shortcomings in care are accepted'.
In a letter NHS Resolution concluded that: "It is accepted that had these failings not occurred Luca would have been delivered in a timeframe when it would have been likely he would have survived." A number of new guidelines and rules have been established at East Lancashire Hospitals NHS after Luca's tragic death which include new CTG instructions and guidance when a deteriorating situation should be escalated and to whom.
Assistant Coroner Kate Bisset returned a narrative conclusion. She said: "An independent investigation by HSIB concluded that Mrs Bentley's care did not reflect the urgency of the situation. Professionals did not act urgently enough or escalate care appropriately.
"Assessment criteria inappropriate to Mrs Bentley's stage of labour were used and physical transfers included delays. Had Mrs Bentley's care been different, Luca would have survived and the care provided to Mrs Bentley is a direct causative factor in Luca's death on June 14, 2020 at the Burnley General Hospital."
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