Stillbirth and Neonatal Death

Mrs K’s son, baby X was tragically delivered stillborn.  There were failings in her care in which warning signs were ignored and baby X’s delivery delayed.

Expert medical evidence confirmed that the CTG trace (a continuous recording of the fetal heart rate used to assess fetal well-being) showed signs, which should have resulted in an urgent medical review.

There were failures to maintain CTG monitoring and a failure to assess Mrs K or to review the CTG trace in full.  Therefore, there was a failure to appreciate the long-term picture of a baby in distress.

Mum had had a healthy and uneventful pregnancy but in the few days before the induction of labour, Mum noticed increased movements from the baby, which she thought was a good sign. Mum and Dad went to the hospital for the induction of labour as planned.

The baby had not been moving that morning, but Mum was not worried because this had been part of the baby’s usual pattern.  

After they arrived at the hospital, the doctors and midwives could not find the baby’s heartbeat. Mum and Dad were initially not informed of the concerns.  

Mum and Dad were eventually told that there was no heartbeat and that their baby had died.  

‍

Mum asked to deliver their baby by caesarean section because she felt that a vaginal delivery would be too traumatic for her. Her request was initially refused because she was told that a caesarean was not in her best interests and there were not enough staff on the ward for it to be done safely. Her request was eventually agreed, but she had to wait until the following day for the caesarean.