Coroner blasts NHS Trust where baby girl died thanks to gross failures in basic medical care - four years after major report exposed blunders
A coroner has blasted an NHS Trust for its culture of defensiveness after a baby girl died due to gross failures in basic medical care.
A coroner has blasted an NHS Trust for its culture of defensiveness after a baby girl died due to gross failures in basic medical care.
James Adeley slammed University Hospitals of Morecambe Bay NHS Foundation for failing to learn lessons from a major report into maternity services which recognised serious failures of clinical care some ten years ago.
He criticised the Trust after the inquest into Ida Lock, a baby who died a week after birth as a result of a serious brain injury caused by poor care at the hands of midwives.
Mr Adeley pointed out multiple missed opportunities for enhanced care during the babys birth including a wholly ineffectual and incompetent resuscitation.
To make matters worse, the senior coroner for Lancashire and Blackburn with Darwen noted similarities with the criticism pointed at the Trust a decade after hearing evidence of a deep seated and endemic culture of defensiveness in respect of maternity incidents.
He went on to criticise the Trusts approach to this inquest as one of lack of transparency and openness and failing to provide relevant information.
Furthermore, he described all its investigations into the babys death as unskilled and superficial.
During the 19-day inquest, Mr Adeley said: Idas death and subsequent investigation is a damning indictment of an ineffective, dysfunctional and callous system that has failed this family at every opportunity presented to it.
Ida Lock was born at Royal Lancaster Infirmary Labour Ward on November 9, 2019, but died a week after she was born
This happened as a result of midwives failing to react to her falling heart beat while mother Sarah Robinson was in a birthing pool
Ida Lock was born at Royal Lancaster Infirmary Labour Ward on November 9, 2019, but died a week after she was born, having been transferred to the Royal Preston Hospital.
This happened as a result of midwives failing to react to her falling heartbeat while mother Sarah Robinson was in a birthing pool, an inquest heard.
The newborn baby suffered hypoxic brain damage caused by oxygen starvation during her difficult birth and the wholly incompetent attempts at resuscitation by midwives.
Mr Adeley has now has issued a prevention of future death report to both the Department of Health and Social Care and the Trust in which he highlighted several concerns.
This included criticisms of the Trust for carrying out inadequate investigations and having a lack of transparency and openness.
The hospital is operated by the scandal-hit University Hospitals of Morecambe Bay NHS Trust, which was investigated in 2015 after eleven babies and a mother died.
Mr Adeley pointed out there were multiple missed opportunities for enhanced care during Ms Robinsons labour.
This included a failure to act on clinical signs that made it inadvisable for Ms Robinson to enter the birthing pool, he said, as well as failure to act on a significant slowing of the babys heart.
He went on to slam the hospital for failing to summon obstetric help at an appropriate time and said the midwives became task focused on obtaining a foetal heart rate and deriving reassurance from unreliable heart rate readings, which led to an avoidable delay.
Baby Ida Lock with father Ryan Lock, mother Sarah Robinson and brother Ethan
Baby Ida Lock, who was born at Royal Lancaster Infirmary Labour Ward on November 9, 2019 with father Ryan Lock
While the coroner said the obstetric delivery of Ida was of high quality, he said the delay in involving the doctor meant Ida was born pale in colour with a low heart rate and brain damage caused by a reduction in oxygen.
Ida was resuscitated for three and a half minutes after her birth, but the coroner said this was wholly ineffectual.
The inquest heard that a paediatric registrar took over and performed a higher quality resuscitation but died a week later.
Delivering his conclusion, Mr Adeley said: Ida was a normal child whose death was caused by a lack of oxygen during her delivery that occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress.
[Her death was] contributed to by the lead midwifes wholly incompetent failure to provide basic neonatal resuscitation for Ida during the first 3 1/2 minutes of her life that further contributed to Idas brain damage from which she died.
Mr Adeley criticised the Trust for carrying out inadequate investigations, maintaining a lack of transparency and openness, and a failure to respond to a detailed complaint letter.
He noted the significant similarities with the criticism made in the 2015 independent investigation, known as the Kirkup Report.
The review ultimately found there had been serious failures of clinical care in the maternity unit of what became the University Hospitals of Morecambe Bay NHS Foundation Trust.
While the coroner said the obstetric delivery of Ida was of high quality, he said the delay in involving the doctor meant Ida was born pale in colour with a low heart rate and brain damage caused by a reduction in oxygen
Ida was born at Royal Lancaster Infirmary but was transferred to the Royal Preston Hospital
It found that avoidable harm was caused to mothers and babies, including tragic and unnecessary deaths, followed by a pattern of failure to recognise the nature and severity of the problem.
In a prevention of future deaths report sent to the Department of Health and Social Care and University Hospitals of Morecambe Bay NHS Foundation Trust, Mr Adeley outlined several matters of concern.
He said he also told of how the investigation into Idas death showed elements of failing to identify significant care issues, brevity, defensiveness.
Mr Adeley said: I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths.
The Trust is ten years on [from the Kirkup Report] and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Idas inquest.
The Trusts approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day.
The coroner raised concerns about the reliability of the Trusts data after hearing evidence into how the organisation failed to report Idas death to the coroners office, among other similar failings.
Ida was resuscitated for three and a half minutes after her birth but the coroner said this was wholly ineffectual. Pictured: Baby Ida Lock with brother Ethan
Mr Adeley said: Ida was a normal child whose death was caused by a lack of oxygen during her delivery that occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress. Pictured: Baby Ida Lock with father Ryan Lock brother Ethan
He criticised their deficient process and said the hospital has chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation.
Mr Adeley continued: All investigations conducted by the Trust to date in respect of Idas death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report.
In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust.
The coroner said the midwife supporting Idas family had not undertaken her required mandatory training.
He said that the non-completion of such training was still an issue at the Trust in 2025.
It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date, he continued.
The report was also addressed to NHS England and NHS Lancashire and South Cumbria Integrated Care Board.
Tabetha Darmon, Chief Nursing Officer, University Hospitals of Morecambe Bay NHS Foundation Trust, said: Losing a child is tragic and our heartfelt condolences go out to Idas parents, family and loved ones.
We are truly sorry for the distress we have caused. We accept that we failed Ida and her family and if we had done some things differently and sooner, Ida would still be here today.
We also acknowledge the additional upset caused to Idas parents and family as a result of the way investigations into Idas death have been conducted since 2019. For that, we are truly sorry.
We take the conclusions from the Coroner very seriously and have made a number of the improvements identified during the inquest.
We are carefully reviewing the learning identified to ensure that we do everything we can to prevent this from happening to another family.
There is still a lot of work to be done, and our teams remain committed to continuously improving maternity services for women and families across Morecambe Bay.
We know none of this can take away the pain Idas family and loved ones will be feeling.
We know we need to do better, and we will be leaving no stone unturned to learn from the ways we failed and improve the care we provide in the future.