Staff at a Nottingham Hospital were more 'reactive than proactive' as an inquest found there were missed opportunities in relation to the death of a baby girl who was born without a heartbeat.
Adele O'Sullivan died on April 7 2021 at Nottingham City Hospital, just 26 minutes after being born at 29 plus weeks.
An inquest into her death, led by Assistant Coroner Elizabeth Didcock, concluded on Wednesday, February 9 that there were a number of missed opportunities to better care for mother, Daniela O'Sullivan, whilst she was on the Lawrence View ward.
However, she said that on a balance of probabilities, the management of Mrs O'Sullivan's care was not a determining factor in Adele's death.
Nottingham University Hospitals (NUH), which runs the City hospital, has apologised to the family.
Delivering her conclusion at Nottingham Council House, Mrs Didcock said that staff were "reactive rather than proactive".
She stated: "I have no difficulty in finding that the delayed examination, the delayed recognition of labour, and the delayed diagnosis of the cause of the vaginal bleeding were missed opportunities to alter the plan of care for Daniela and Adele.
"But for these missed opportunities, would the outcome have been different in this case and would Adele have survived? On the evidence before me, I find that it is certainly possible, but for all of the reasons set out in this judgement, I cannot and do not find this on a balance of probabilities."
The inquest, which heard from from medical professionals and midwives between February 2 and 4, found that Daniela had bleeding and then back and abdominal pain on the evening of April 6.
It was not recognised that this was likely to be caused by a marginal abruption, followed by onset of preterm labour, leading to the separation of the placenta from the uterine wall in the second stage of labour.
By this time delivery was thought to be imminent, but was complicated by Adele’s compound presentation - where an arm appears next to the main presenting part -as she travelled down the birth canal.
The assistant coroner said that if an obstetric assessment had been carried out then there would have been a "plan and a controlled and managed move to labour suite", meaning Mrs O'Sullivan could be better monitored.
She also said that an an examination completed at 12.44am was "incomplete", saying that a proper assessment would have led to a more urgent transfer to the labour suite than that which was undertaken.
NUH, who also run Queen's Medical Centre,launched a serious incident investigation in light of Adele's death.
Led by deputy medical director Dr John Walsh, it found that there were delays in moving Mrs O'Sullivan to the labour suite, adding that she had been ‘moved to the back of the queue’.
It acknowledged the ward was busy on the night, but said communication between doctors was "poor".
Ms Didcock described the findings as "robust" and praised the trust's improvements since, but expressed concerns over the lack of staff accounts and interviews included in the report.
She accepted the post mortem report which determined Adele died of 1a) Severe intra-partum hypoxia/Ischaemia in the context of preterm delivery.
1b) Retro-placental haemorrhage/haematoma (so-called marginal abruption)
1c) Ascending maternal genital tract infection, preterm prolonged rupture of membranes, and oligohydramnios
2) Compound fetal presentation (head, hand, and shoulder) at delivery.
Ms Didcock added: "I wish to extend my sincere condolences to Adele’s parents, Daniela and David.
"I am so very sorry for your loss and it is my sincere hope that this investigation and inquest have assisted you in coming to a greater understanding of the circumstances surrounding Adele’s death."
Director of Midwifery at NUH, Sharon Wallis, said: “We would like to offer our sincerest condolences to Mrs and Mr O’Sullivan for the loss of their daughter, Adele.
"This was a rare, complex and truly tragic case, and we apologise from the bottom of our hearts for the delay in our medical team reviewing Mrs O’Sullivan.
"We realise this may not have affected this heart-breaking outcome, but our teams are committed to learning from this case.
“Since the summer of 2021, we have new leadership in Maternity and we are working with our teams and healthcare partners to make improvements to our service as quickly and efficiently as we can.”
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