Failure by a NHS Trust hospital to put into place a properly managed birth procedure led to the death of an unborn baby, 48 hours later.
Arriving at the hospital after her waters had broken, and despite the presence of the unborn baby’s first faecal matter, the mother, aged 31, was discharged. The hospital advised the mother to return the next day when she would be either “admitted to the labour ward or be monitored and treated with antibiotics, as appropriate.”
The next morning - more than thirty hours after her waters had broken - the mother returned once more to hospital. Despite experiencing contractions every ten minutes and discharging blood, labour was not induced and antibiotics given instead. By mid-afternoon the mother had still had not been admitted to the labour ward and was in pain. With the commencement of labour imminent, a cardiograph (CTG) to monitor the foetal heart rate was only put into place after a further two hours had elapsed.
One hour later, and despite noting that the unborn baby’s heart rate had increased, the medical notes indicate that the next CTG monitoring was not scheduled for another two hours. By midnight, the mother was given relief for her severe pain but monitoring of the baby’s heart had still not happened even when a midwife was in attendance at 2.30am.
Nearly twelve hours after the last CTG had been taken - at 5.20 am - the next heart monitor was begun but there was a difficulty in detecting the unborn baby’s heart rate. Nearly ninety minutes later, the mother was finally transferred to the labour ward but tragically, the baby was still-born when delivered.
During the subsequent case hearing, it was shown that the mother had received negligent care at the hospital. The evidence presented strongly suggests that it was “likely” the baby would have survived if the mother had been admitted to the labour ward before midnight, yet there was no management by the obstetric and midwifery staff, and no plan had been put into place to commence delivery.