A 5 week Inquest concerning the death of Ida Lock found that the serious brain injury which was due to a lack of oxygen was caused by the failure of the midwives to deliver her urgently when she was in distress, which was then compounded by their failure to provide basic neonatal resuscitation upon birth.
The Inquest led by Coroner James Adeley identified that there were 8 missed opportunities to prevent the course of events for Ida. Ida died on 16 November 2019 due to her injuries.
It was found that Ida had suffered a period of distress during labour which was a result of an abnormally slow heart rate when her mother, Sarah Robinson, was in labour. During birth, a slow heart rate for a baby can indicate that they are in distress and that they need to be delivered urgently in order prevent severe brain injury. The slow heart rate can be an indication that their brain is not getting enough oxygen and when this is prolonged this can cause a baby to suffer from a brain injury which can led to death or life long disabling injuries. In these circumstances early delivery is essential and may prevent the development of these injuries. In Ida’s case the failure to identify her distress was then compounded by a failure to provide basic neonatal resuscitation when she was born during the first 3 and a half minutes of her life.
University Hospitals of Morecambe Bay NHS Foundation Trust, (‘the Trust’) responsible for the hospital where Ida was born stated ‘we failed Ida and her family and if we had done some things differently and sooner, Ida would still be here today.’ They also stated that ‘we are carefully reviewing the learning identified to ensure that we do everything we can to prevent this from happening to another family.’
The Trust, however, are not unfamiliar with criticism of their maternity care. Dr Bill Kirkup CBE was tasked to investigate concerns about the serious incidents in their maternity services provided to mothers, birthing people and babies during the period of 2004 to 2013. The report identified that there were ‘disturbing catalogue of missed opportunities’. One of the recommendations identified that they needed to review ‘skills, training and duties of care.’ The Trust states about the report ‘whilst our teams have worked extremely hard to make significant improvements, there is still work to do.’ There is a clear need to continue to focus on the recommendations of the report considering Ida’s death.
This, however, is not an issue that is isolated to this Trust. We have reported previously about Nottingham University Hospitals NHS Trust pleading guilty to charges over failures to provide safe care and treatment to babies and their mothers. Nottingham University Hospitals NHS Trust are also under investigation with the Ockenden review after signification concerns were raised over the quality and safety of their maternity services. There has also been the well publicised investigation into the Shrewsbury and Telford Hospital NHS Trust. Last year we also reported on the CQC’s investigation which found that many maternity failings are becoming more widespread. Further consideration and reflection on the care mothers, birthing people and their babies receive is required. There are also reports calling for a national maternity inquiry, rather than separate inquiries for each hospital or Trust.
Lauren Kerse, Associate Director and Specialist Medical Negligence Solicitor from MDS, said “Our thoughts are with Ida Lock’s family, and we can only imagine the grief that they have experienced because of her avoidable death and the difficulties experienced in understanding how this was caused. The root causes of her death are something that we have seen before, and we hope that the recommendations of the Coroner are implemented to prevent further harm”
Update
Since the above story was reported, the BBC has reported that £2m of payments were made by NHS Resolution to the Trust after they self-reported that they had achieved all 10 standards for promoting safe treatment under the Maternity Incentive Scheme (‘the scheme’). NHS Resolution is the department of the NHS that manages clinical negligence liabilities, and every hospital trust is required to contribute financially for the management of this.
The scheme was implemented to provide a financial rebate to hospital trusts who demonstrate a core set of safety actions to enhance maternity safety. Maternity claims and injuries that have been caused to babies during birth can result in substantial compensation due to the significant lifelong disabling injuries that can be caused, and the compensation received reflects the life-long care that is needed for these injuries.
University Hospitals of Morecambe Bay NHS Foundation Trust self-reported that they had met all 10 safety standards in 2018 resulting in a payment of £1,288,241 as well in 2019, the year Ida Lock died, when they were paid a further £734,122. Both of these payments were rebated from the trust’s contribution towards the liabilities for maternity and birth injury claims, as well as a share of the contribution from other less well performing NHS Trusts.
One of the 10 core standards that need to be met to obtain the incentive is the use of the National Perinatal Mortality Tool, which is designed to investigate perinatal deaths which can ‘lead to improvements in how healthcare is provided to newborns and their mothers or parents.’ The Trust also had to self-report that they were implementing minimum training requirements which included training on obstetric emergencies, fetal monitoring and neonatal life support.
The Trust’s own internal ‘root cause analysis’ into the factors that were involved in Ida Lock’s death concluded there were no issues in her care, but the independent Healthcare Safety Investigation Branch later identified numerous failings. The coroner was also critical of the failure to provide ‘basic neonatal resuscitation’ after her birth.
Under the scheme there is the option for reverification where NHS Resolution can ask the Trust to re-verify their submissions, and if appropriate, NHS Resolution has the option to ask for any monies to be repaid.
In light of the conclusions regarding Ida Lock's death, this information about the payments received is concerning. Comment is awaited from the Trust
MDS is a specialist medical negligence law firm. We specialise in claims involving cancer, maternity, and cauda equina syndrome. Our expert solicitors represent clients all around England and Wales, and we are dedicated to helping people who have been injured by medical negligence.
Our solicitors have extensive experience of representing clients and their families whose lives have been affected by an injury during birth. Click here to read more about how we can help you, and here to read one of our client’s stories.
If you are concerned about any care that you or a member of your family has received, please contact our experienced team on 0116 254 7456 or email: enquiries@moosaduke.com. You can also enquire online by clicking here.
