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Inquest: coroner gives verdict of misadventure after baby dies one day after birth

This case study demonstrates the expertise of our Clinical Negligence team who represented the family at the inquest into the death of their baby son, who died at one day old, having been born in an extremely poor condition.

The mother was under the care of Darent Valley Hospital (Dartford & Gravesham NHS Trust) and community midwives. This was her second pregnancy. During her third trimester, she had concerns about the size of the baby and felt much bigger during this pregnancy than her last.

She was diagnosed with polyhydramnios at 36 weeks. A growth scan at this time showed the baby's estimated weight to be 7Ibs 11oz. She felt extremely uncomfortable and was suffering from backache. She had a 17 month old son to look after.

She was advised during an antenatal appointment with the obstetric registrar at Darent Valley that she was at risk of cord prolapse because of the diagnosis of polyhydramnios. As expected, the mother was extremely concerned about this given that she was caring for her eldest child and her husband was often travelling due to his job in sales. However, she was refused induction or caesarean section.

She requested a second opinion and that consultant agreed she should be booked in for induction at 39 weeks. As it happened, she felt her waters breaking two days before induction was booked (although it was later revealed that her waters had not broken) and was admitted to the antenatal ward.  

Labour failed to progress and despite syntocinon drip for 24 hours. Having been in hospital for nearly two days with contractions but not progression, her waters were broken artificially. It appeared that her waters had not in fact broken as she thought but no test was done on arrival at the hospital to confirm.

A few hours later, she was given the option to have caesarean section due to the length of time she had been in labour but was assured that it was safe to carry on and aim for vaginal delivery. She agreed to continue for another two hours. The consultant noted the possibility of a large baby and advised the midwives to be vigilant for shoulder dystocia at birth.

Over the next few hours, she progressed to full dilatation and began pushing with a midwife present, who later called for assistance from a more senior midwife. The head was delivered but the shoulders were stuck. No episiotomy was performed at that time and the midwife pulled the call bell to summon a doctor. The call bell came away in her hand and did not set off the alarm. She therefore had to call for help out of the door of the delivery suite.

A doctor attended and performed an episiotomy straightaway, allowing delivery of the baby. The baby was born in an extremely poor condition but was finally resuscitated and transferred to Medway Maritime Hospital. He sadly passed away the next day.

The baby weighed 10Ibs 2oz at birth, classing him as macrosomic. The post mortem report showed glucose in the pancreas, suggesting gestational diabetes.  

We represented the family at the inquest in Gravesend, Kent and were able to ask questions to the various witnesses called from the Trust. It was extremely upsetting for the family to have to go through events again and see the doctors and midwives called to give evidence.

Having heard all of the evidence, the coroner gave a verdict of misadventure.

Jennifer Waight specialises in inquests and fatal accident cases. If you would like to ask Jennifer a question about inquests or you have a general query about medical negligence, contact her on 01892 701374 in confidence.

We have one of the largest and most experienced specialist medical negligence teams in Southern England including London. Our team of highly experienced lawyers has the depth and range of expertise essential in this sensitive and often complex area of law. Our clinical negligence team is very proud to be ranked Number 1 in both the Legal 500 and Chambers and Partners UK.