Changes made at Leeds Teaching Hospitals NHS Trust after baby’s death

Leeds General Infirmary
Leeds General Infirmary
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AN INVESTIGATION in to a baby’s death at Leeds General Infirmary has led to changes in practices at Leeds Teaching Hospitals NHS Trust, an inquest heard.

Joanne Noad’s baby son Reece Noad-Caine died from brain damage after being starved of oxygen when he became stuck during birth due to shoulder dystocia on November 20 2011, an inquest at Wakefield heard.

Miss Noad had suffered problems with shoulder dystocia when she gave birth to a previous child four-and-a-half-years previously.

Reece, who weighed 9lb 8oz, had been due on November 5 and Miss Noad was admitted to a midwife-led unit on November 19 2011 to have him induced.

The inquest has heard how in April 2011 community midwife Katherine Hewitson had referred Miss Noad to a consultant and noted ‘query shoulder dystocia’ on her notes.

But the inquest heard Mrs Hewitson had ticked the low risk box on Miss Noad’s notes.

Miss Noad was seen by locum consultant Dr Bramara Guruwadayarhalli in June 2011, who has told the inquest she did not have access to paper records of Miss Noad’s two previous births notes when she saw her.

The inquest has heard Dr Guruwadayarhalli was not aware Miss Noad’s notes would have been on a computerised system.

Giving evidence, Dr Collette Sparey, consultant obstetrician at Leeds General Infirmary, discussed the trust’s report on the death with Deputy Coroner Melanie Williamson.

Dr Sparey said: “The shoulder dystocia meant she should have been categorised as high risk.”

Dr Sparey said Miss Noad should have been given an appointment with a consultant at around 36 weeks to assess the size of the baby and to discuss birth method options.

Dr Sparey said the trust is working on introducing a computerised system so midwives can access records of mothers’ previous pregnancies and births.

Dr Sparey said a report following the investigation recommended that all trust staff have access to electronic medical records. The inquest was told there is a now a new risk assessment form on pregnant mothers which sets out what is expected if a previous birth has involved shoulder dystocia.

The inquest continues.

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