Leeds hospital trust apologises over baby’s death

Leeds  General Infirmary
Leeds General Infirmary
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A HOSPITAL trust has apologised to the parents of a baby boy who died soon after being born at Leeds General Infirmary following a catalogue of errors relating to his mother’s care.

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.

His mother Joanne Noad had suffered problems with shoulder dystocia when she gave birth to a previous son, Aaron, at Leeds General Infirmary in November 2006.

But she was classed as a low risk for Reece’s birth.

Recording a narrative verdict after a three-day inquest at Wakefield Coroner’s Court, Deputy West Yorkshire Coroner Melanie Williamson, said: “Clinicians failed to properly evaluate the deceased’s mother’s previous pregnancy and failed to appreciate her pregnancy in 2011 was high risk. Specifically, there was poor planning for the birth of the deceased.”

Miss Williamson said at 2.10am on November 2011, the machine that monitored Reece’s heart rate during labour indicated a pathalogical reading, adding: “But there was a failure to respond in an appropriate and timely manner.”

Miss Wiiliamson said that if Reece, who was born at 3.09am on November 20 2011, had been delivered on or before 2.47am he would have survived.

Peter Merchant, representing Leeds Teaching Hospitals NHS Trust, told the inquest: “The trust would wish to apologise to Miss Noad and Mr Caine for the omissions in care.”

Miss Noad said after the inquest: “I have lost a perfectly healthy child which again makes it even harder to come to terms with. Knowing that people who I trusted to care for me and my baby used assumptions and their own judgement calls and did not always follow NHS guidelines of good practice, is very hard to accept.”

“I have heard that certain procedures have been introduced and altered as a result of this tragedy and for this I am grateful as I hope they ensure that women are given nothing but the best maternity care.

“Nothing should be taken for granted during pregnancy or labour and risk needs to be managed appropriately, not dismissed as in my case.

“Women need to be better informed of what problems arise during delivery in a discussion with staff prior to discharge.”

Rachelle Mahapatra, a partner and medical law expert at Irwin Mitchell’s Leeds office, said: “Reece’s death has had a devastating effect on Joanne’s life and she has been to hell and back trying to understand why more wasn’t done by midwifery staff to help her son.

“The admission of liability gave Joanne some accountability but she understandably wanted a thorough investigation for Reece’s inquest to ensure no stone was left unturned in getting to the bottom of exactly what went wrong.

“We hope that now the hearing has concluded she can begin the process of rebuilding her life.

“We would also like to see confirmation from the trust that the root causes identified in its own internal investigation following Reece’s death have been learnt from to ensure no other mother has to go through the same horrendous ordeal.”

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 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.

Dr Collette Sparey, consultant obstetrician at Leeds General Infirmary, previously told the inquest that 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.

And she said a report following the investigation recommended that all trust staff have access to electronic medical records.

The inquest was told the trust has introduced a new risk assessment form on pregnant mothers which sets out what is expected if a previous birth has involved shoulder dystocia.

A spokesman for Leeds Teaching Hospitals NHS Trust said after the inquest: “The trust would like to once again offer our sincere condolences to Miss Noad and Mr Caine on the death of their son, Reece.

“Furthermore, the trust would like to apologise to Miss Noad and Mr Caine for the omissions in care delivered.

“We would like to reassure those parents currently using our maternity services that lessons have been learned and that significant improvements have been made to our patient record systems.”

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