Newborn baby's death due to hospital 'neglect', inquest rules
- Credit: Family
A newborn baby that died at Hinchingbrooke Hospital would have survived if she had been delivered two hours earlier, a coroner ruled.
Baby Charlotte Middleton died 40 minutes following her birth after staff at the Huntingdon hospital “failed to act upon warnings which meant she was born two hours after she should have been”, an inquest heard.
If she had been delivered when she should have been, Charlotte would have survived, the court was told.
Her mum Laura, 40, was diagnosed with gestational diabetes during her third pregnancy. She had the condition during her other two pregnancies, so was aware of the risks and that her blood sugar levels had to be monitored.
Laura and her then husband Chris, 39, had a discussion with midwives and doctors, and opted for an elective caesarean section at 37 weeks due to having a large baby.
Upon admission to Hinchingbrooke Hospital, Charlotte’s heart rate was monitored using a cardiotocography (CTG) machine.
The next morning after admission, Charlotte’s heart rate was found to have slowed and Laura was rushed to theatre for delivery.
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Baby Charlotte was born in poor condition at 9.54am on July 18 2019, and died shortly afterwards.
Following her daughter’s death, Laura instructed medical negligence experts at Irwin Mitchell to investigate her care under the North West Anglia NHS Foundation Trust (NWAFT).
It comes after the Trust admitted to “failings in ante-natal care” which “at least materially contributed” to Charlotte’s death.
An inquest held on Friday (January 29) at Huntingdon Town Hall, concluded Charlotte died as a result of complication of maternal diabetes in pregnancy and that neglect contributed to her death.
Coroner Lorna Skinner QC found staff did not act upon a series of Laura’s blood sugar level readings and an abnormal CTG reading.
The scan demonstrated “a need for Charlotte’s urgent delivery”, the coroner said.
The scan reading combined with Laura’s pregnancy history should have seen Charlotte delivered by 7.40am at the latest.
If she had been delivered by then she would have survived, the coroner ruled.
In a bid to learn lessons from what happened the Trust has since introduced a scheme entitled "Charlotte Training" in the hope of helping to prevent further neonatal deaths.
The coroner recorded a narrative conclusion.
Laura and Chris have two other children together, Isabelle, nine, and Harry, five.
Laura said after the hearing: “We were all really looking forward to having Charlotte in our lives, and Isabelle and Harry couldn’t wait to have a little sister.
“When Chris arrived at the hospital, I couldn’t bear to tell him what had happened. The senior midwife broke the news to him and brought Charlotte straight in.
“She put her into Chris’ arms and I watched his heart break. That will stay with me forever.
“Walking out of the hospital without our baby devastated us, and the drive home was spent in silence.
“Losing Charlotte is something we’ll never get over and we’ll never be the same, but it’s important for us as a family that we include her in as much of our life as possible and we talk about her every single day.
“I keep imagining Charlotte as a happy teething baby playing with her brother and sister.
“Sadly, that’s something we’ll never see, and while we can’t change what’s happened, we’re determined to campaign to improve care for others.”
“Charlotte Training” is now mandatory training at the NWAFT surrounding diabetes in pregnancy, CTG interpretation and human factors.
Dr Kanchan Rege, chief medical officer and deputy CEO at NWAFT, said: “Following a thorough investigation, the Trust has ensured lessons have been learned in this tragic case and further training has also been put into place in order to prevent this from happening again.
“The safety of the women in our care during pregnancy has always been paramount and ensuring the healthy delivery of a baby is something we strive for in every birth.
“We have been in touch with the family throughout and offer our sincerest condolences and continued support, should they require it.”