Home > Publications > Selected CasesHealth > Selected Investigations Completed AprilJuly 2002 > Part II, Case no. E.387/99-00
Complaint against Nottingham City Hospital NHS Trust (the Trust)
Complaint as put by Mr L
1. The account of the complaint provided by Mr L was that on Saturday 19 April 1997, his wife was admitted to the Nottingham City Hospital (the hospital) at 0200 hours in the early stages of labour. She received epidural anaesthetic during the first stage of labour and was fully dilated at 1140 hours. The second stage of labour progressed slowly and Mrs L was given the drug, Syntocinon, to induce stronger contractions. At 1525 hours, Mrs L was assessed by the Senior Registrar (the Senior Registrar) who decided to carry out a trial of forceps. However, this procedure was delayed by the presence of another patient awaiting a Caesarean section in theatre.
2. Mrs L was transferred to theatre shortly before 1700 hours where an attempt at forceps delivery was made. After one unsuccessful attempt by the Senior House Officer (the SHO) and two unsuccessful attempts by the Senior Registrar, the Senior Registrar decided to proceed to Caesarean section. The baby, Baby L, was delivered at 1731 hours and, sadly, pronounced as stillborn at 1815 hours.
3. On 12 June, Mr L complained to the Trust about the standard of care and treatment received by his wife. An independent review panel (IRP) held on 13 August 1998, found no faults in the management of Mrs L’s labour but recommended, on the advice of the Consultant Obstetrician, that a second opinion on the cause of death be obtained from an independent paediatric pathologist (the Consultant Paediatric Pathologist). His report of 15 February 1999 concluded that Baby L had died as a result of a heart attack due to the presence of cerebral tissue in the heart.
4. Following the IRP, Mr L complained about the care provided to his son on 19 April 1997. However, the Trust told him that this issue could not be pursued through the NHS complaints procedure. Mr L remained dissatisfied.
5. The matters investigated were that:
(a) the management of Mrs L’s labour and the delivery; and
(b) the care provided to Baby L following his birth, were unsatisfactory and inadequate.
Investigation
6. The statement of complaint for the investigation was issued on 4 February 2000. The Trust’s comments were obtained and relevant documents including clinical and nursing records were examined. One of the Ombudsman’s investigators took evidence from Mr and Mrs L. Interviews were also conducted with the midwifery, medical and neonatal members of staff involved in the care of Mrs L and Baby L. However, the second Midwife and the Paediatric Registrar who are working abroad could not be interviewed for this investigation. Three professional assessors (the Assessors) – a Consultant Obstetrician and Gynaecologist, a Consultant Neonatologist, and a Director of Midwifery and Gynaecology serviceswere appointed to advise on the clinical issues and were present for interviews with appropriate Trust staff; a tour was made of the labour suite and theatres. The Assessors’ report is attached at Annex A. In addition, a Senior Lecturer in histopathology was asked to review the histological sections of brain, lungs and placenta, and her report is attached at Annex B.
Documentary evidence
7. The post-mortem report of 28 April 1997 on Baby L, included the following:
‘… CENTRAL NERVOUS SYSTEM: On reflecting the scalp there are seen to be two foci of subaponeurotic (sheath of tissue) bruising symmetrically placed over each parietal region each approximately 3 x 4cm but no evidence of any skull fracture seen. The brain is swollen and congested and weighs 440g. (expected for a term infant 355g.) There is a very small amount of liquid blood in the posterior cranial fossa but there is no haemorrhage in the anterior or middle fossa and the falx and tentorium (parts of the brain) are intact. …
‘… RESPIRATORY SYSTEM: … The lungs are completely unaerated and unexpended …
‘… COMMENT: … Death appears to have occurred as an acute event during the second stage of labour so the deceased was a fresh stillbirth. …’
8. At the request of the Coroner, a histopathology report was prepared on 19 June 1997 which included the following:
‘… The findings in the lungs are those of an intrauterine pneumonia in association with marked meconium aspiration (inhalation of faeces passed by the baby in the womb). When an infant is [sic] utero becomes hypoxic (lacks oxygen) for whatever reason the physiological responses include expelling meconium into the amniotic fluid cavity and making deep gasping respiratory movements. The amniotic fluid containing meconium is thus aspirated down into the lungs. If any inflammatory cells are present in the amniotic fluid (resulting from ascending infection in the mother) these will also be aspirated into the lungs. This would appear to be the case here, although in the sections of placental membranes examined no florid infection was seen although some subchorionic (under the chorionic – a part of the placenta) inflammatory response was identified and inflammation of the membranes can be patchy. It is difficult to prove absolutely that the inflammatory cells present are all maternal, i.e. that they have simply been aspirated as a terminal event rather than representing a primary illness in the infant. However, if the aspirated infected material in the infant’s lung has been present for some time the infant, itself, would respond with an acute inflammatory reaction. However, there is no evidence that this has happened for example, the pulmonary blood vessels of the infant do not contain increased numbers of acute inflammatory cells and the umbilical cord vessels (carrying blood to and from the infant) do not show inflammatory response. …’
9. The report of the Consultant Paediatric Pathologist, commissioned by the Trust following the IRP, included the following:
‘Comment
‘The history is that of a term baby who appeared to be, according to the documentation, considered entirely well during the second stage of labour until he was unexpectedly found dead at delivery. There were no known significant risk factors and, although the second stage was acknowledged to be long, it was not considered unduly so.
‘There is evidence that the baby was considered well with no evidence of distress at least up to [the] time of the initial trial of forceps and perhaps shortly afterward. The clinical history suggests death occurred very rapidly somewhere between 16.50 (approximately) and delivery at 17.31.
‘…
‘Cause of Death
‘The significant finding in the histology, is the presence of small plugs of cerebral white matter in small pulmonary arteries and intra-cardiac vessels. This cerebral tissue is present due to unrecognised cerebral trauma which has occurred most likely during one of the forceps procedures although the possibility of trauma during caesarean section cannot be excluded entirely.
‘Embolisation of cerebral tissue following forceps is a rare, but well documented, phenomenon. Most of the pathology reports document cerebellar folia within the major vessels of the lung although the presence of white matter has been described. The precise source of the white matter cannot be determined with absolute certainty although it is most likely cerebellar in origin. The emboli appear to result from cerebral tissue being sucked into a traumatised venous sinus. The embolus then passes via the systemic vein through the right atrium and ventricle to the lung.
‘The disruption of the venous sinus results, at least in some and possibly in most instances, from occipital osteodiastasis (the separation of two adjacent bones) in which there is inward displacement of the occipital bone.
‘Cardiac embolisation associated with the pulmonary embolus is also well recognised. Cardiac embolisation would appear to follow paradoxical embolisation with the tissue passing from the right atrium, through the foramen ovale, into the systemic circulation and thence into the coronary arteries.
‘In many instances, embolisation of brain tissue is associated with death in the minutes or hours after delivery and may be due either to interference with pulmonary circulation or the effects of the cerebral trauma. Even survival of days has been recorded.
‘In this case, however, rapid death is almost certainly due to the cerebral tissue in the coronary circulation causing immediate cardiac arrest. This mechanism is fully consistent with the clinical history of an apparently well baby dying rapidly from a sudden event within a 30 – 40 minute period, shortly after an appropriate medical procedure.
‘The post mortem does record the presence of liquid blood in the posterior fossa. Disruption to venous sinuses may be easily missed and osteodiastasis needs to be specifically looked for and/or appropriate lateral skull X-rays need to be taken to demonstrate its presence. Recognising the relevant cerebral damage may also require specific search, although this may not always be found.
‘While embolisation of cerebral tissue has more commonly been associated with forceps procedures that involve rotation, it has been recorded following use of 'outlet' forceps and following breech delivery. I am not in a position to comment in any detail as to why this form of trauma should have occurred in this particular case. External evidence of trauma is not always identified although I note that the post mortem report does record symmetric bruising suggesting appropriate positioning of forceps blade at one point during the procedure.’
10. I have seen literature on case studies documenting the embolisation of brain tissue in neonates, following use of forceps (Hauch et al, and Baergen et al).
Mr and Mrs L’s evidence
11. Mr L’s letter of 26 May 1999 to the Ombudsman included the following:
‘We have finally had an [IRP] into the care Mrs L received at the Nottingham City Hospital on 19 April 1997. However, we remain dissatisfied. We feel that the [IRP] evaded a lot of the controversial issues and by and large ‘Sat on the Fence’. …
‘The length of the second stage of labour
Mrs L had a Second Stage…which lasted 6 hours. … [The Senior Registrar] admitted … that risks to babies do increase with a long second stage of labour. We feel that the Hospital owe an apology for leaving Mrs L this long …
‘…
‘The Administration of the Drug Syntocinon
The [IRP] comment that Syntocinon was administered in accordance with hospital protocols. This is simply not correct …
‘Monitoring of the fetal heartbeat
In the Theatre, the fetal heartbeat was not monitored but the medical records incorrectly show that the heartbeat was listened to after the trial of forceps. …
‘…
‘Failure of [the Delivery Suite Manager] to manage the Labour Suite
… We feel [the Delivery Suite Manager] did not co-ordinate her staff properly and we feel that this contributed to the excessive second stage of labour. The reason for the excessive stage of labour has never been explained to us. …
‘…
‘We do not feel that we were given informed consent for Trial of Forceps
[The Senior Registrar] did not properly explain the reasons for the trial of forceps. He did not give us the correct assessment of the chance of success. We were against such intervention. We asked [the Senior Registrar] what the chances were of a successful trial of forceps. [He] told us that he was 80% confident. … if we had been given a proper assessment we would have insisted on an immediate Caesarean and Baby L would be alive today!’
12. At interview, Mrs L told the Ombudsman’s investigator that she was admitted to hospital in labour at 0200 hours on 19 April 1997, and went immediately to the labour suite where she was checked internally. The labour suite was not busy and she received one to one care from the midwife. At 0600 hours she was given an epidural and at that stage everything was fine. Although the medical records stated that she was fully dilated at 1140 hours, Mrs L believed that she might have reached this stage much earlier because at around 1000 hours she had felt pressure to push.
13. Mr L said that around noon the Midwifery Team Leader came into the room and told them that the monitor had been faulty for a couple of weeks. She adjusted the belt around Mrs L’s stomach and said that there was nothing to worry about. At 1245 hours the first midwife gave Mrs L a vaginal examination and asked the SHO to review her because her labour was not progressing. This took place at 1325 hours when the SHO incorrectly recorded that Mrs L had been fully dilated for one hour, instead of almost two. She started Mrs L on Syntocinon (Oxytocin) to induce stronger contractions but failed to give her a further vaginal examination before doing so.
14. Mr L observed that although there seemed to be no shortage of midwives, there was no continuity of care, or proper handover between the first and second Midwife at 1350 hours. The Delivery Suite Manager did not see Mrs L to assess the situation and she failed to organise the staff properly. He believed that the first Midwife would have been aware of the length of time that his wife had been fully dilated and would have called the SHO to review her again at an earlier stage than had the second Midwife. He believed that small mistakes had combined to create a significant problem and that although the hospital had made light of them as minor issues, they contributed to the wider picture.
15. Mr L claimed that the Senior Registrar had been in a state of panic when asked by the SHO to review Mrs L, especially when he had returned the second time. The operating theatre was occupied by an emergency Caesarean case which delayed matters for Mrs L while the Senior Registrar went off for an hour to deal with it. When Mr L asked what his wife should do in the meantime if she felt the urge to push, he was given conflicting information. The Senior Registrar said that she should go ahead but the Midwife told him that she should hold on.
16. Mr L explained that he had been very much against instrument intervention and had therefore questioned the Senior Registrar about his suggestion that the baby might be delivered by means of forceps. When asked about the likelihood of success, the Senior Registrar had said that although forceps might not work, there was an 80% chance that they would. He had advised that a trial of forceps in theatre should be attempted and that Mrs L could not be left any longer. Despite this, she was left for over an hour before transferring to the theatre. The Senior Registrar told them that the baby was in slightly the wrong position and that he would be turned and pulled out. Mr and Mrs L had accepted this advice although Mrs L had been quite prepared, if necessary, to have a Caesarean section. She had felt positive about a trial of forceps and had signed the consent form because an 80% chance of success sounded good. Mr L was adamant that he would have refused permission for the procedure to go ahead if the likelihood of success had been less.
17. Mrs L said that she was taken off the monitor for her transfer from the labour suite to the operating theatre where she was violently sick. She believed something happened at this stage as she was in extreme pain and felt out of control. Mr L said that although the second Midwife claimed to have used a Doppler (a hand-held machine which sends out ultrasounds to pick up the velocity of blood flow and the fetal heart), and to have obtained a normal foetal heart reading after the forceps attempts, he was convinced that she failed to monitor the baby’s heart after transfer from the labour suite. The Trust claimed that the Doppler batteries had been low. This was unacceptable; equipment should have been in proper working order. He had observed the whole procedure and since he neither saw nor heard the Doppler, he concluded that the medical note showing a fetal heart rate of 140 had been falsified by the second Midwife.
18. Although no further vaginal examination was performed prior to the trial of forceps, Mr L was told at that stage by the Senior Registrar that the baby was in the right position and should come straight out. Mr L was standing at his wife’s head and witnessed the procedure. The Senior Registrar introduced the forceps blades, one after the other, and handed them to the SHO. She pulled on them once and handed them back to the Senior Registrar who then gave two, hard, pulls. Mr L described him leaning back as if engaged in a ‘tug-of-war’, and knew immediately that it must be bad for the baby. He also believed that since the Senior Registrar had applied the forceps, he should have employed them rather than letting the SHO attempt delivery.
19. After the failed trial of forceps, Mr L was told that he would not be permitted to be present for the Caesarean section. As it happened, his wife was not able to have a general anaesthetic so he was able to be present for the birth. He remembered the Senior Registrar’s look of surprise and shock as Baby L was delivered. Mrs L said that she realised immediately that something was wrong because Baby L did not cry. She feared that she, too, might die at that moment and received no reassurance from anyone.
20. The Anaesthetic Registrar started to congratulate them when Baby L was delivered but stopped in his tracks when he saw the baby’s colour. The Paediatric SHO handled Baby L, held him upside down and took him to an incubator in the corner of the operating theatre. Mr L said that it was panic stations from then on. The Anaesthetist Registrar left Mrs L’s side to assist with intubating Baby L, the Paediatric SHO rushed next door to get something, and the midwife could be heard paging people in the background. Mr L believed that had Baby L’s heart rate been monitored, a paediatric registrar could have been in attendance to give immediate assistance at the point of birth. His reason for bringing the complaint about the paediatric care was that the cord blood taken to measure the oxygen levels implied that Baby L had been dead for ten minutes. In other words, he had died at the trial of forceps and the foetal heart reading in the medical records was false. Mr L listed three significant issues relevant to the paediatric care, namely, that the medical staff had had to go next door to collect something, that they had been unable to intubate Baby L, and that there had been a delay in calling the Paediatric Registrar.
21. After resuscitation attempts were stopped, the Paediatric Registrar asked Mr L whether he wanted a post mortem and advised him that it would be beneficial to find out why Baby L had died. The Senior Registrar spoke to him the following morning and had appeared embarrassed when Mr L had raised the issue of what he considered to be the brutal use of forceps.
22. Following her ‘horrific’ experience with Baby L, Mrs L feared what might happen if she had another baby. The acting Head of Midwifery told her that she would have another Caesarean and everything would be all right. Mrs L was given a booklet but believed that parents needed to know what effect such an incident would have on a subsequent birth. When she saw the Consultant Obstetrician he did nothing to allay her fears and she was made to feel that she was asking too many questions. She gained the impression that he was trying to plant the idea in her mind that infection had been the cause of Baby L’s death. He told her that 10% of women had vaginal infection that crossed the placenta and ‘wiped the baby out’. When he had said at a meeting the following July that overwhelming infection had been the cause of Baby L’s death, she had been made to feel that she was to blame. She wondered if she or her husband might have contracted an infection. It caused her extreme anxiety about the outcome of a subsequent pregnancy. In the aftermath of what happened she lost confidence and did not want to return to work. She was unable to face her friends and had even felt suicidal.
23. Mr L hoped that the Ombudsman’s investigation would result in an apology and an acceptance from the Trust that procedures had not been adhered to. If mistakes had been made they should be admitted and lessons learned from them. He also wanted removal of those parts of the medical records that he considered had been falsified.
Trust’s response to the Ombudsman
24. In his formal response to the statement of complaint on behalf of the Chief Executive, the Director of Service Development wrote:
‘Mrs L was admitted to [the] Hospital in early labour at 02.00hrs on 19 April 1997.
‘On initial examination Mrs L was found to be 1cm dilated. An epidural was sited at 05.55hrs via which analgesia was given. Labour progressed normally and Mrs L was fully dilated by 11.40hrs. The first stage of labour took 10 hours 5 minutes and was uneventful.
‘After I hour 45 minutes in the second stage of labour uterine contractions were considered inefficient as they were mild. Syntocinon infusion was commenced at 13.38hrs and Mrs L began active pushing at 14.15hrs. Mrs L was assessed at 15.00hrs at which time it was noted that there had been no further progress made in the second stage. At 15.25hrs [the Senior Registrar] examined Mrs L at which point trial of forceps was discussed. Although [the Senior Registrar] could not be 100% certain that a forceps delivery would be successful he felt there was a strong clinical case for undertaking the procedure. [He] decided that the attempt should be made in theatre. There was no foetal distress and therefore no particular concerns with either Mrs L or the foetus.
‘At that point in time there was already a patient in theatre, however, because of [the Senior Registrar’s] assessment of Mrs L, her case was not seen as an emergency and the decision to wait until the theatre became free was taken. There is evidence that operative intervention in the second stage of labour is not warranted merely because of the length of time elapsed. In this case there was no foetal distress noted.
‘…
‘Mrs L was transferred to theatre at 16.52hrs. The Syntocinon infusion was continued up until transfer to theatre. [The Senior Registrar] re-examined Mrs L. At that time the foetal heart beat was 140 beats per minute and there was no suspicion of distress. Although not previously complaining of nausea Mrs L began to vomit. [The SHO] under the supervision of [the Senior Registrar] applied the Neville Barnes forceps but there was no descent of the foetal head. [The Senior Registrar] made two further attempts. There was some descent with the first but none with the second. Following the forceps attempt [the second Midwife] used a sonicaid to listen to the foetal heart beat.
‘The decision was taken to proceed to a Caesarean Section. Mrs L had expressed a request to have a general anaesthetic but due to vomiting at the time this could not be undertaken and therefore the procedure was carried out under epidural.
‘A stillborn male infant, Baby L, was delivered at 17.31hrs weighing 3.3kgs. All attempts at resuscitation were undertaken but were unsuccessful.
‘… Although no inadequacies were identified in the care of Mrs L at this stage, the procedure relating to monitoring of fetal heart whilst in theatre was changed. [See paragraph 29]
‘…
‘An [IRP] held on 13 August 1998 found no faults in the management of Mrs L’s labour but recommended that a second opinion on the cause of death be obtained from an independent [consultant] paediatric pathologist.
‘In reviewing this case [the Consultant Paediatric Pathologist] noted that “there were no significant risk factors and, although the second stage was acknowledged to be long, it was not considered unduly so”. [The Consultant Paediatric Pathologist] also commented on the fact that there was no evidence of distress up to the time of the trial of forceps.
‘With regard to the cause of death in Baby L’s case, cerebral tissue was present in small pulmonary arteries and intra-cardiac vessels. This is a rare but recognised complication of both forceps and Caesarean deliveries. …
‘…
‘Mr L’s [subsequent] letter to the Trust … set out a complaint regarding the paediatric care his son received following delivery by Caesarean Section. Due to the time which had passed and that four members of staff had not been employed by the Hospital for some considerable time, the Chief Executive advised Mr L that she was unable to pursue the issues raised in his letter as part of the Complaints Procedure. She did, however, as a gesture of goodwill, offer to undertake a review of all relevant documentation relating to the questions raised.
‘[The Consultant Paediatric Pathologist’s] report was then received. The Chief Executive suggested in writing that any action on reviewing the paediatric care provided for Baby L be deferred until after the meeting between Mr and Mrs L, the Chief Executive and Medical Director, on 8 April 1999, to discuss [the] report.
‘Mr L wrote to the Trust on 13 April 1999 asking for a full apology. A final letter was sent to Mr and Mrs L on 26 May re-iterating that, as discussed at the meeting, it was not possible to say whether the injury to Baby L was sustained during the forceps procedures or during the Caesarean Section and that the time of death could not be deduced accurately from the cord blood as suggested by Mr L …
‘The Trust accepted [the Consultant Paediatric Pathologist’s] conclusion that Baby L had died as a result of a heart attack due to the presence of cerebral tissue in the heart. …
‘Each stage of the investigation into the care of Mrs L, during her labour and delivery, has shown that the staff acted within accepted practice.
‘The injury to Baby L was a rare but known complication. The investigations have shown that it was not possible to identify whether the injury was caused during the forceps procedure or the Caesarean Section. The staff undertook all possible action in trying to resuscitate Baby L. …’
25 In a further communication from the Trust, the Chief Executive wrote with reference to paragraph 31 below, and the Assessors’ advice on page 50 of Annex A:
‘A slow infusion of oxytocin 40U in 500ml dextrose does not indicate how much was given and therefore is not conclusive of an excessive dose. It should be noted that although not as a direct consequence of this case, the Syntocinon policy has been updated since this case.’ (see paragraphs 28 and 29).
Complaint (a) the management of Mrs L’s labour and delivery was unsatisfactory and inadequate
Trust Protocols
26. The Trust’s protocol on Patients to be seen by Medical Staff on Admission, which was current at the time of the events of this complaint, includes the following:
‘If problems arise, either in the obstetric unit or on the gynaecology ward, when the duty registrar is otherwise occupied, the second on [call] gynaecology registrar should be called to provide assistance. …’
27. The Trust’s Guidelines for the Management of the Second Stage of Labour with an Epidural in situ current at the time state:
‘1. Provided that there is no fetal or maternal distress, a woman with an effective epidural, may when diagnosed to be fully dilated, be left for up to one hour before being encouraged to push. The fetal heart should be continuously monitored and recorded.
‘2. If, after one hour, the epidural is still very effective, then a vaginal examination should be performed. Where there has been some progress, i.e. descent, rotation, and the maternal and fetal condition are still satisfactory, then the woman can be left for a further one hour before routine pushing is commenced. In some instances it may be appropriate to reduce the rate of the epidural infusion. Staff are reminded to keep the Labour Suite Co-ordinator fully informed of examination findings. Where there has been no apparent progress, the management of the mother should be discussed with the medical staff.
‘3. Women are not to be in the 2nd stage of labour for more than three hours unless a senior member of the obstetric staff is monitoring their progress.
‘4. Staff should note that for record keeping the length of the 2nd stage should still be recorded from full dilation to delivery of the baby, but they can also record the length of time pushing as a separate figure.’
28. The Trust’s Oxytocin Regime current at the time, included the following:
‘Syntocinon 5 units in 500 mls of 5% Dectrose (final concentration 10mU/ml) …
‘…
‘Maximum dose for primigravidae
120 mls/hour = 20mU/minute
Seek Consultant medical advice before further increase …
‘…
‘Increase by 12mls/hour every 15 minutes:
‘…
‘120 mls/hour = 40mU/minute (Absolute maximum dose) …’
29. At the time of the events of this complaint the Trust were in the process of ratifying their protocol for the Use of Oxytocin. It was updated in December 1999 when the following additions were made:
‘For primigravidae…
‘…
‘If the increase in the rate of Syntocinon infusion is agreed with the Consultant then the following suggested regime should be used:-
‘Syntocinon 10 units in 500mld of 5% Dextrose (final concentration = 20mU/ml)
‘…
‘Increase infusion by: 15ml/hour every 30 minutes until adequate contractions.
75ml/hour 25mU/minute
90ml/hour 30mU/minute
‘Absolute maximum dose
‘MANAGEMENT OF SECOND STAGE OF LABOUR:
‘Consider augmentation of the second stage in primigravidae when:
1. An epidural is in situ and contraction strength is not optimal (remember that naturally as second stage approaches contractions increase in both strength and frequency because of the Ferguson reflex).
2. There is persistent malposition.
‘…
‘Augmentation with Syntocinon in the second stage of labour must be a registrar decision after a full review of the case.
‘…
‘In general the case should be reviewed by the registrar after 60 minutes.
30. As a result of this case, an appendix to the Trust’s Protocol for Cardiotocograph in Labour was added in July 1999, as follows:
‘The CTG monitor will be taken into theatre when a mother is transferred for trial of forceps in theatre. Where possible the CTG will be continued until the baby is either delivered vaginally or the decision to proceed to emergency C/S (Caesarean section) is made. …’
31. Following the events of 19 April 1997, the Anaesthetic Registrar lodged a statement with the Trust’s anaesthetics department. It included the following:
‘… At the obstetrician’s request [prior to the trial of forceps] I commenced a slow intravenous infusion of oxytocin 40 units in 500ml 5% dextrose in order to aid uterine contractions…’
Trust’s evidence
32. The Midwifery Team Leader said that she had been on duty from 0715 hours to 1515 hours. She reported to the Delivery Suite Manager and was responsible for a minimum of two other midwives who would have been on duty at the same time. She did not think that the labour suite had been busy on that day because she remembered being able to provide patients with one to one care.
33. Responding to Mr L’s assertion that the cardiotocograph (CTG) monitor in his wife’s room had been faulty, the Midwifery Team Leader explained that if a woman was on her side – as was likely with an epidural in situ – the equipment did not work well. She recalled adjusting the transducer (a device used to monitor uterine contractions) around Mrs L and leaving the room after about five minutes. She did not stay to see whether the transducer worked since the first Midwife would have reported anything that was subsequently found to be wrong with the equipment. Since all faulty equipment was taken out of service, the Midwifery Team Leader concluded that Mr L had misconstrued what she had said. She had very little to do with the couple on that day but recalled that there were no problems with Mrs L and labour had appeared straightforward. She was therefore very shocked at the outcome for the baby.
34. The first Midwife said that she had come on duty that day at 0715 hours and had gone through the usual handover procedure. She would have been told about the situation of all the women in the labour suite before being allocated particular patients, in line with hospital policy that each woman was cared for by a named midwife. She would have gone through the partograms (graphic records of the course of labour) of her allocated patients with the midwife handing over care in order that she knew the patient’s history and was aware of any particular problems or features. If minor issues arose while caring for a woman in labour, or if she required support and help, she would first approach the Midwifery Team Leader. She could also go at any time to the Co-ordinator of the labour ward if there was a significant problem, and consult a doctor directly if the need arose.
35. The labour suite was not excessively busy on the day in question and the first Midwife only had Mrs L to look after. Mrs L would have been monitored externally through two belts; one recording the foetal heart rate (FHR) and the other her uterine contractions. The first Midwife was aware of Mr L’s complaint that the monitor had been faulty and understood this to be a reference to the contraction belt and not the FHR monitor. However, she was certain that the monitors were working properly since, if not, they were always taken out of service for repair. She would have noticed, as a matter of course, the date and the lights on the monitor indicating that it was functioning properly.
36. The first Midwife noted her vaginal examination of Mrs L at 0940 hours as being ‘difficult’, which may have been because Mrs L was over anxious or because the procedure was uncomfortable. At that stage, Mrs L was dilated 8cm and, at a rate of 1cm per hour, she was expected to be fully dilated to 10cm at 1140 hours. She gave Mrs L another vaginal examination at that time, which confirmed that she was fully dilated. At 1240 hours she consulted the Delivery Suite Manager for advice, reporting that Mrs L had been fully dilated for one hour and had no urge to push. She received instructions from the Delivery Suite Manager to reassess the cervix and she performed a further vaginal examination five minutes later. At about 1300 hours the first Midwife requested an obstetrician’s review because Mrs L’s contractions were diminishing. Later she went through the partogram with the SHO, telling her about the vaginal examination and the contractions. She did not notice that the SHO incorrectly recorded Mrs L as being fully dilated for one hour, instead of two. In accordance with labour suite protocol, Syntocinon could be started after two hours in the second stage of labour, following assessment by a doctor. The SHO subsequently prescribed Syntocinon for Mrs L which was commenced at 1338 hours.
37. The first Midwife explained that there was a cross over period at the end of her shift when staff made a ward round, skimmed the notes of all the women in the labour suite and then handed over particular patients to named midwives. At this stage her practice was to read from her notes and let the midwife taking over pick up on the doctor’s notes. She informed the second Midwife that Mrs L had been fully dilated at 1140 hours.
38. The Delivery Suite Manager said that her duties included co-ordinating all staff on duty, responsibility for the equipment and stores, and general housekeeping. There were three labour wards and three teams engaged in all spheres of midwifery. Usually three midwives from each team were on duty in the labour suite, which had 17 identically equipped delivery rooms, and a room with a birthing pool.
39. The Delivery Suite Manager came on duty at 0830 hours on the day in question and remembered that it was not a particularly busy shift because she was able to get on with some paperwork. There were no problems with Mrs L, or any of the other women, at that stage. At 1230 hours the first Midwife sought her advice about Mrs L. She reported that Mrs L had been fully dilated for about an hour, that the epidural was effective and that she had no urge to push. The protocol for management of the second stage of labour with an epidural in situ allowed for a woman to be left without pushing for up to two hours provided both she and the baby were satisfactory and there were no other risk factors. The woman must be assessed after approximately one hour to check for progress and, if there was progress, she could be left for the second hour. When there was no progress, pushing should commence after two hours, unless the woman was being managed by a senior member of the medical staff. The aim was to deliver the baby within three hours of full dilation.
40. The Delivery Suite Manager said that she would examine a patient to check presentation or palpation, for example, if asked to do so. On this occasion there was no cause since the first Midwife, in whom she had complete confidence, had no concerns about Mrs L. Having been instructed to reassess the patient, the first Midwife reported back that there was no progress and that she had asked the SHO to review her. The SHO subsequently advised the Delivery Suite Manager that Mrs L had been started on Syntocinon and that the baby’s heart rate was fine. Syntocinon was often needed to override the effect of the epidural but only administered after discussion with an SHO or Registrar, and prescribed by a doctor. The time when Mrs L had reached full dilation would have been noted on the board in the labour suite which recorded progress.
41. The Delivery Suite Manager explained that a woman in active second stage of labour was not left. There was continuous monitoring in passive second stage and, if there were no concerns, the woman was checked at least every 15 minutes. Generally, there was constant monitoring by the midwife who would explain to the woman what was happening, the workings of the monitor and how the intercom worked. She said that a woman would not usually be in the second stage of labour for as long as Mrs L and had the Senior Registrar decided that it was a straightforward case of forceps delivery, a second registrar could have been called to do it. If the baby had not been well, another theatre would have been opened up as there were two theatres and always a dedicated team of theatre staff for the Obstetricians. At weekends the second team would be in the main theatre but, in an emergency situation, staff would be called to come in from home. Mrs L would not have been left if there had been decelerations (a slowing of the foetal heart rate), or if the foetal heart rate had fallen to a slow rate and stayed there.
42. The Delivery Suite Manager saw the Senior Registrar prior to handing over to her colleague at about 1500 hours, and was aware that he was about to operate on another patient needing a Caesarean section. That operation was subsequently delayed. Having examined Mrs L, the Senior Registrar told the Delivery Suite Manager that it would be safer to do a trial of forceps in theatre. She was advised that Mrs L should not carry on pushing and to top up the epidural if necessary to keep her comfortable. She then handed over to the Co-ordinator.
43. The Delivery Suite Manager explained that problems never arose with the monitors because a piece of malfunctioning equipment would immediately be taken out of service and labelled for repair. There was sufficient equipment to replace any taken out of use. Equipment was moved around the labour suite and it would have been impossible therefore for the Midwifery Team Leader to know whether a particular piece of equipment had been giving trouble. If a woman was on her side, it was not always possible to obtain a tocograph recording of her contractions until she had been re-positioned. It was this process that Mr L had very likely misunderstood.
44. The Delivery Suite Manager had been very surprised about the outcome for Baby L. The following day she saw Mr L’s letter giving instructions that the baby was not to be removed from the hospital as he wanted an independent post-mortem. She had dressed Baby L, noting no excessive moulding (the compression of the foetal head caused by its passage in labour) or forceps marks. As was the procedure in such cases, a photographer had taken pictures of the baby. Mr L wanted to see Baby L and the Delivery Suite Manager had taken Polaroid photographs of them together in the sitting room set aside for such purposes. She was aware that Mrs L had not seen Baby L and had wanted to give her the opportunity to do so before the post-mortem. She visited Mrs L on the ward and left the photographs with her.
45. The Delivery Suite Manager considered that they had failed Mrs L because she had never come to terms with the loss of her baby. She might have had more success if she had still been on duty but, by the time she had seen Mr L, 36 hours had elapsed. Although she tried everything she could to reach out to the couple, he had ‘put up blocks’ by that stage. In distressing cases such as these, staff drew support from each other and from the chaplaincy.
46. The Co-ordinator said that she had come on duty at 1330 hours and that day had not been busy. She took over from the Delivery Suite Manager and went through the usual handover procedures, which included a report on all the women in the labour suite. Mrs L was in the second stage of labour at that time and all was well. The Co-ordinator did not see the SHO but spoke to the Senior Registrar who said that he wanted to take Mrs L to the theatre for a trial of forceps. He explained that there was a Caesarean section waiting which he would do first. The Co-ordinator was aware that Mrs L had been in the second stage of labour for some time and that she had been started on Syntocinon because her contractions had diminished. She popped in to see Mrs L and noted that the foetal heart rate was satisfactory.
47. The Co-ordinator explained that despite the delay in taking Mrs L to the theatre, the second Midwife would have been with her the whole time, requesting relief if necessary. The Co-ordinator considered her a competent Midwife. There had been no indication that a second theatre should be opened up. She knew that Mrs L had been in the second stage for longer than two hours but was not aware that it had been nearly six. She did not necessarily consider this to be too long. If a patient was fully dilated with an effective epidural and all was well, she could be left for an hour for the baby’s head to descend. If she was examined again and everything was still all right then she might be left for longer. It was the aim, however, to deliver a woman within three hours of the second stage. There would have been cause for concern if there had been any other problems with Mrs L. However, the foetal heart rate had been fine.
48. The Co-ordinator explained that although Mrs L was not monitored for the short distance between the labour suite and theatre, the second Midwife would have listened via a portable sonicaid (diagnostic ultrasound machine for detecting the foetal heart rate). As a result of this case, the CTG monitor was now taken into theatre for a trial of forceps and rechargeable sonacaids were used. In response to Mr L’s suspicion that the medical notes had been falsified and written at a later stage, the Co-ordinator emphasised that the Midwife’s first priority was to the patient and not the contemporaneous writing up of notes.
49. The Co-ordinator was not present in theatre to witness the trial of forceps and Caesarean section and the first she was aware of the stillbirth was when the cord bloods were brought out of the theatre to be analysed. It was an awful result and she wondered what could have happened. Resuscitation attempts were stopped shortly after she arrived in the theatre and she recalled seeing Mr L briefly. She had not had any direct involvement with the couple and from the way Mr L appeared, she felt she could not approach him. As she removed Baby L to the counselling room she noted that Baby L’s head looked undamaged and that there was no moulding (the effect on the shape of the foetal head as it passes through the birth canal).
50. The day after the incident, the Co-ordinator made a verbal report to the acting Head of Midwifery. She described the Senior Registrar as having been devastated by what had happened. A counsellor had now been appointed for the staff and they continued to draw support from each other at such times.
51. The acting Head of Midwifery said that she received the news of Baby L’s stillbirth by telephone on the day in question. She was told that Mrs L had received good care but that Mr L was seeking an independent post-mortem. This was an unusual request because they had a very good paediatric pathologist at the hospital. She gave instructions to ensure that this happened in accordance with Mr L’s wishes.
52. On the following Monday, the acting Head of Midwifery went to the ward and collected the medical notes for examination. She noted that the second stage of labour had been long at 5 hours 51 minutes. She looked at the recordings and saw that the foetal heart rate had not been listened to around the time of Mrs L’s transfer to theatre. She noted that the SHO had recorded the cervix as being fully dilated for one hour instead of two. She noted the delays caused by the unavailability of the theatre, and the locked theatre door (see paragraph 104). Having broken all these factors down, however, she concluded that Mrs L’s labour had been reasonably managed. She collected statistics for that year and found that 96% of women had delivered within three hours of the second stage of labour. Apart from Mrs L, only three other women had delivered after a second stage of five or six hours and their babies had been born in good condition.
53. Following a verbal report from the Co-ordinator, the acting Head of Midwifery met with the midwives and doctors. Low risk women did not need continual monitoring unless an epidural and Syntocinon were in place, in which case it was appropriate. If the CTG was normal, the monitor was not taken into the theatre. Following this case, however, the monitor was always taken in for a trial of forceps to provide the necessary evidence with which the hospital could defend itself, if necessary. She spoke to the second Midwife who expressed great shock and surprise at Baby L’s death. Although the sonicaid batteries had been low, the second Midwife was sure that she had heard the foetal heart rate. The acting Head of Midwifery had no trouble believing her because she was a competent midwife. She was proud of her midwives who were all of good calibre and it was a matter of much regret that, as a result of this case, the second Midwife had given up midwifery.
54. The acting Head of Midwifery had visited Mrs L on Monday afternoon and was told that she wished to see her in the evening when her husband could be present. That subsequent meeting had been very difficult. Although the acting Head of Midwifery was prepared for, and would have readily understood, a hostile reaction from the couple, what transpired was cold and unemotional. She tried to be as sympathetic as possible and asked Mr and Mrs L whether there were any aspects of care with which they were unhappy. Mr L replied that they would await the findings of the post-mortem. She explained the ‘Care Card’ system, which was intended to ensure that staff were alerted to a previous stillbirth and that special care would be provided if Mr and Mrs L should decide to have another baby.
55. The acting Head of Midwifery was not surprised when Mr L lodged his complaint. Normally, she would have sat down with the parents and gone through the partogram and notes with them. In this instance, however, Mr and Mrs L had taken all the information, conjured things up in their minds and reached their own conclusions. A subsequent meeting in July 1997 with the Consultant Obstetrician at which she had hoped to set up a rapport with Mr and Mrs L, had proved very unsatisfactory for everyone. However, it had acted as a learning curve for the Trust and she would take more charge when reviewing complaints in future to ensure that a logical sequence was followed.
56. The acting Head of Midwifery had never heard of a case of an embolism of cerebral tissue being found in the coronary arteries, as described in the Consultant Paediatric Pathologist’s report. The L case had been a topic for discussion at the Labour Suite Working Group which was formed of midwives, senior staff and consultants. It had also been discussed at a perinatal audit meeting, which had found that the clinical procedures involved had been acceptable. They had failed to reach a conclusion as to why Baby L had died.
57. The SHO said that she came on duty at 0830 hours and went through the usual handover procedure at the board in the labour suite, where they were given a brief history of each patient. Two sets of SHOs and Registrars were involved in the handover but it varied as to whether the consultant was present. The SHO recalled that it was not particularly busy in the labour suite that morning but became busier around lunchtime. The level of activity depended not so much on the number of patients but on what was happening with them. There had been a problem with a patient that she was called to review who was having a Caesarean section that afternoon.
58. The SHO first reviewed Mrs L at 1325 hours at the request of the first Midwife. She was unable to recall how she had come to record Mrs L as fully dilated for one hour instead of two. She gained the impression that the contractions had tailed off, which was why Mrs L’s labour was not progressing. This was, in retrospect, unusual. She would have ascertained that there was no sign of obstruction. She gave instructions to start Syntocinon with the idea of optimising the conditions they had, and keeping an eye on what happened once Synotocin was administered. The Co-ordinator would have been aware of the situation.
59. At 1500 hours, the SHO was preparing to go to the operating theatre to assist the Senior Registrar with a Caesarean section. She reviewed Mrs L at 1515 hours, gave her a vaginal examination and found that her contractions had improved. Mrs L had been pushing for 50 minutes at that stage and there was no foetal distress. She informed the Senior Registrar of the position and he used the opportunity of a delay with the patient in theatre, to review Mrs L. At that stage she had been in active second stage of labour for one hour and each case was considered on its merits. Some epidural patients did not experience sensation if the block was such that they could not feel contractions, and it therefore took longer for them to push effectively. Doctors looked for progress, together with satisfactory maternal and foetal monitoring signs, to decide whether to allow a patient to continue to push.
60. The SHO said that the first she knew about the trial of forceps was when the Senior Registrar repeated the vaginal examination and explained the procedure to Mrs L. The proposal did not surprise the SHO because the case was clinically suitable, involving, as it did, a baby that was not big and in the optimal position. She did not recall the Senior Registrar mentioning a figure in regard to the likely success of delivery by this means. There was no discussion about opening a second operating theatre because of the delay with the other Caesarean patient, and such a decision was for the Senior Registrar and the Anaesthetist to make. Foetal distress would have been the trigger for taking positive action in this regard.
61. The choice of forceps depended on the position of the baby although, as in this case, Neville Barnes were the most commonly used. There was no suggestion that Mrs L’s baby would require turning during the procedure. Although a forceps delivery could be done in the labour suite, a trial of forceps was always done in theatre and it was a clinical decision as to which was appropriate. At this point in her career, the SHO had been involved in about seven forceps deliveries. Junior doctors practiced on a model pelvis and doll, and watched more experienced doctors perform the procedure on patients before attempting it themselves. If a junior doctor encountered a problem, the senior would take over. Forceps locked without difficulty when appropriately placed, and they had been easily applied in Mrs L’s case. The SHO explained that once the forceps were in position she would have waited for a contraction and maternal effort to make her attempt at delivering the baby. As there was no descent with her first pull, the Senior Registrar had taken over.
62. The SHO explained that she was not involved with Mrs L’s transfer from the labour suite, where she had been monitored by CTG. Although the SHO remembered hearing the foetal heart between the trial of forceps and Caesarean section, she could not recall whether this was by CTG or hand-held sonicaid. She and the Senior Registrar stood on either side of Mrs L, whose husband would have been able to see what he wanted of the operation. His view would have been obscured during the trial of forceps, however, when Mrs L’s legs were raised and draped. Mrs L’s Caesarean had been straightforward and there was no difficulty extracting the baby.
63. This had been the SHO’s first experience of a full term stillbirth and both she, and the Senior Registrar, were surprised, upset and concerned about what had happened. She visited Mrs L on the ward that evening but she did not want to be disturbed. The SHO returned the following morning to express her condolences and to give Mrs L the opportunity to ask questions. Later in the day she also saw Mr L who was very upset and angry, and concerned that his wife should receive the best of everything. He did not mention anything specific about the care and treatment provided by the SHO, but she was not surprised when he subsequently lodged his complaint.
64. The SHO felt that generally there was enough support available to her after such events. In this case she discussed what had happened with the Senior Registrar, the Consultant Obstetrician and the midwives, with whom she went through the medical notes. In retrospect, she said that she should have given Mrs L a vaginal examination when first prescribing Syntocinon, but had relied on the examination of a very experienced midwife. She considered, however, that there was nothing she could have done that would have made a difference to the sad outcome.
65. The Senior Registrar said that he came on duty at 0830 hours on the day in question. After a verbal handover with the previous registrar and a ward round with the SHO, he saw antenatal patients as required. At weekends, a senior and a more junior on-call registrar provided cover for each other in emergencies. The labour suite was generally fairly busy and at around the time of Mrs L’s delivery, there had been another patient requiring a Caesarean. There were two theatres and two middle grade seniors capable of performing Caesarean sections, but only one anaesthetist. However, the on-call consultant anaesthetist would have come in, if necessary.
66. The Senior Registrar first saw Mrs L at 1525 hours when the Delivery Suite Manager asked him to review her before he commenced the Caesarean section in theatre. He was told that Mrs L had been in the second stage of labour for sometime and he was aware that she was not contracting well. He studied the partogram and noted that this was a first baby, which made the signs ‘less sinister’. He performed a vaginal examination and the CTG trace was normal. The notes told him that Mrs L had been fully dilated for a period in excess of three hours, and pushing for one. Had it not been for the delay caused by the patient already in theatre, he would have proceeded with forceps at this stage. Although he could have asked the other registrar to do one or other of the procedures, he sensed that the baby might not come out. With the possibility of failure, he considered that it would be better to do the trial of forceps in theatre where they could proceed straight to Caesarean, if necessary. He sometimes put a figure on the likelihood of success of a trial of forceps but was unable to recall whether he had mentioned one to Mrs L, or whether her husband had been present when he had explained what he wanted to do. He had believed, however, that there was a chance that he could deliver the baby this way.
67. The Senior Registrar confirmed that the baby was being continually monitored and everything was satisfactory at this time. It had therefore been acceptable to return to Mrs L after completing the Caesarean section already in theatre. At this point she had been in the second stage of labour for four hours with one hour’s pushing. Although, in general, a second stage would be of one hour’s duration, it could extend to three hours with an epidural, including one hour’s pushing. Depending on the circumstances and a normal CTG, an even longer period, although not ideal, might be reasonable. Up to transfer from labour suite to theatre, the baby would be monitored by CTG. Thereafter, prior to the trial of forceps, the baby’s heart would be externally monitored by means of a Doppler.
68. The Senior Registrar explained that the placing of forceps and the application of traction were not, in themselves, particularly difficult. The important stage in the procedure was the initial and thorough assessment of the case. This included assessing whether the baby was in good condition and whether it would stand up to instruments, studying the maternal condition and analgesia, and diagnosing the position of the baby’s head and the pelvic size. Junior doctors studied training videos and practiced on a model doll and pelvis. They watched seniors demonstrate on patients before carrying out the procedure themselves under supervision.
69. In the case of Mrs L, the SHO had applied the forceps without difficulty and pulled once. Owing to the fact that nothing happened with the first pull, and as the SHO was not very strong, the Senior Registrar had taken over. The number of attempts made was a matter of experience. He looked for progress and it was worth going beyond three pulls in some cases. Although there was some descent of the baby with his first pull, there was none with his second, and he therefore proceeded to Caesarean section. This revealed that the baby’s position had been correctly diagnosed, and there was no difficulty getting him out.
70. Following the stillbirth, the Senior Registrar telephoned the news to the Consultant Obstetrician who would not necessarily have been expected to come into the hospital to see the parents. The Senior Registrar had been devastated by the incident and concerned that something might have happened to Baby L during the course of delivery. Although there had been no external signs of injury, he wondered whether the forceps might have caused some sort of trauma, such as a fractured skull or tears to the brain membrane. He reported the case to the Coroner because it was so unusual. He visited Mrs L on the ward the next day and, although she did not want to see Baby L, she appeared to be coping better than her husband who was very withdrawn. He discussed the findings of the post-mortem with Mr L soon after the event, and then saw the couple for a routine follow-up in the clinic six weeks later.
71. The Senior Registrar had never heard of the cause of death as given by the Consultant Paediatric Pathologist and considered it strange that this had not been discovered at the post-mortem. Since the forceps had been correctly placed, he did not see how they could have caused such an event. He had no personal knowledge of a baby death from forceps and had not made any changes to his practice as a result of this case. His personal opinion was that Baby L may have been distressed for sometime and that this had not been picked up by routine monitoring. When routine monitoring by CTG was normal, there was a 99% chance that the baby was all right. He wondered whether something could have happened during the resuscitation attempts.
72. The Anaesthetic Registrar said that at about 1600 hours on the day in question he was in the operating theatre with the Senior Registrar attending an emergency Caesarean patient. The Senior Registrar told him about Mrs L and his plan for a trial of forceps in theatre, proceeding straight to Caesarean section if it failed. There was no discussion about opening up a second theatre for Mrs L but if the obstetricians had decided that there was a need to do so, another operating team could have been called upon. Prior to topping up Mrs L’s epidural on the labour suite at 1645 hours, the Anaesthetic Registrar had a discussion with her about the pros and cons of general anaesthetic and epidural pain relief. Although he knew from her notes that in the event of a Caesarean she wanted a general anaesthetic, she had recently eaten solids and vomited. He explained to her that a general anaesthetic would be very unwise in the circumstances and she accepted his advice to have epidural pain relief.
73. The Anaesthetic Registrar explained that he would not have been involved in Mrs L’s transfer to the theatre as he would have gone ahead to prepare to receive her. He could not remember how Mrs L was monitored but this was usually carried out by means of an audible sonicaid. He tended to notice abnormal changing tones and did not remember anything untoward about the monitoring of the patient on this occasion. During the procedures that followed he was seated at the operating table to the left of Mrs L’s head and Mr L – whose view of what was happening would have been obscured by the drapes covering her legs – was on her right. After the failed trial of forceps, the Anaesthetic Registrar repositioned Mrs L for the operation and checked that the anaesthetic block was sufficiently dense.
74. The Consultant Obstetrician said that although he had been Mrs L’s nominated consultant, he not seen her personally in the antenatal clinic since he dealt mainly with complicated pregnancies. Her antenatal care had been largely managed by her GP. The Consultant Obstetrician was not on duty on Saturday 19 April 1997, and would not have been called into hospital for a trial of forceps unless there was something unusual about the case. He learned of the stillbirth from the Senior Registrar by telephone either the same evening, or the following morning. The incident had been totally unexpected and the Senior Registrar could offer no explanation as to why it should have happened. Usually, parents were encouraged to have a post-mortem to discover why the baby had been lost and the hospital had its own excellent perinatal pathologist for this purpose. However, Mr L had already made a written request for an independent post-mortem.
75. The Consultant Obstetrician visited Mrs L on the ward the following Monday, having first been briefed by the midwives as to how she was coping. He told Mr and Mrs L that there were issues that needed to be investigated, such as those of possible trauma and infection. He explained that there were situations in which it was impossible to identify the cause of an outcome such as Baby L’s but stressed to them the need to investigate to try to find answers. At the subsequent IRP, the Consultant Obstetrician had expressed his concerns that there should be a second pathologist’s opinion. Mr L appeared deeply suspicious of everything that was said to him and showed no emotion.
76. The Consultant Obstetrician explained that the usual procedure after a stillbirth was a debriefing with the medical staff to gather all the information, following which he would set aside a morning for a meeting with the parents. Before this could happen, however, Mr L had sent a letter of complaint to the Trust and they had been obliged to proceed down the complaints procedure route. Together with the acting Head of Midwifery, he had an extremely unsatisfactory meeting with Mr and Mrs L the following July. He did not meet with them again and the matter became increasingly entrenched in the complaints process. To his knowledge, Mrs L was the only woman following a stillbirth who had not returned for subsequent pregnancies, and he was unhappy that the hospital had ‘lost it’ in respect of this case. However, by the Monday morning following the tragedy, Mr and Mrs L had ‘put up the shutters’.
77. The Consultant Obstetrician considered that Mrs L’s care had been good. The problem had declared late in labour, but Mrs L had been well looked after and there had been no complication with the Caesarean. The actual length of a second stage of labour was not as important as the way in which it was monitored, its progress and how it was managed. As regards whether a second theatre should have been opened up, the Consultant Obstetrician considered that the Senior Registrar had managed resources well. Mrs L and her baby had been all right at the time and the Senior Registrar had therefore proceeded with the Caesarean already in theatre. The Senior Registrar was an excellent and well-trained doctor and the SHO was competent and got on well with staff and patients alike. Generally doctors did not get much support after events such as these although, given the constraints of time, the Consultant Obstetrician tried to be as supportive as possible. The L case had been discussed in detail at the monthly perinatal meeting and no one had been able to establish why the stillbirth had occurred. The post-mortem report had concluded hypoxia (deficiency of oxygen in the tissues) and the histology report prepared for the Coroner had found neutrophils (a type of white blood cell) in the lungs, indicating infection. He had reassured Mrs L over the telephone that she did not have an infection.
78. The Consultant Obstetrician considered that the report of the Consultant Paediatric Pathologist was excellent and had resolved the question of what had happened, explaining the inexplicable and refuting the possibility of infection. The cause of death as given in the report was previously unknown to him, but he thought that the embolisation of cerebral tissue might have happened during the trial of forceps.
79. The Consultant Obstetrician described some of the changes that had been put into effect as a result of this case. Monitors were now transferred into theatre with the mother for a trial of forceps which provided documentary evidence about the condition of a baby. The protocols relating to Syntocinon had also been reviewed to take account of new data.
Findings (a)
80. In reaching my findings I have taken account of the Assessors’ views at Annex A. Mrs L’s labour was uneventful and she progressed, unaided, to full dilation at 1140 hours. The assessors have identified several delays in the progression of her labour from this point, however, which resulted in an unacceptably long second stage.
81. An hour after full dilation, during which Mrs L had no urge to push, the first Midwife sought advice from the Delivery Suite Manager who instructed her to carry out a vaginal examination. Twenty minutes later the first Midwife asked for Mrs L to be reviewed by an obstetrician because her contractions were diminishing. The SHO reviewed her at 1325 hours and prescribed Syntocinon to induce stronger contractions. The Assessors advise me that this should have been accompanied by a medical plan for Mrs L to commence active pushing with the Syntocinon contractions, and for further review after an hour. It was not satisfactory to prescribe Syntocinon in the absence of an action plan. The Assessors do not consider that it was unreasonable for the SHO to rely on the vaginal examination undertaken by an experienced midwife but note that such practice has now been changed.
82. The fact that Mrs L had been fully dilated for two hours with diminishing contractions at this stage, should have alerted the SHO to the possibility of cephalo-pelvic disproportion (where the baby’s head is too large for the pelvis). The SHO checked for obstructionwhich occurs when there is something stopping the head from descending such as a small pelvis, or the foetal head in the wrong positionbut was under the impression that Mrs L had only been fully dilated for one hour. If the lack of progress in the second stage had been appropriately considered, the Senior Registrar should have been consulted so that he could examine Mrs L, with a view to ascertaining whether there was an element of cephalo-pelvic disproportion or malposition (i.e. not the usual position of occipital anterior which, being the smallest diameter of the head, is the normal delivery position of the baby) and whether, at that stage, a forceps delivery should be attempted.
83. A further delay occurred at 1500 hours when, despite having been pushing for 50 minutes, Mrs L was encouraged to continue while the obstetricians were busy with another patient. I am advised that this was unreasonable, given the length of time that Mrs L had been fully dilated. It was also unfortunate that Mrs L was left uncertain as to whether she should push whilst waiting her turn for the theatre. It is impossible to say in this case whether being encouraged to push efficiently would have changed the outcome. I am also advised that the vomiting she experienced was not an uncommon occurrence in labour.
84. By the time Mrs L was reviewed by the Senior Registrar at 1525 hours, she had been fully dilated for three and three quarter hours. There was a further delay because the Senior Registrar decided to do a trial of forceps in theatre (not in the labour suite room) when the theatre was already occupied by another patient. Mrs L eventually transferred to theatre at 1645 hours at which point she had been in the second stage of labour for five and a half hours. Although there is no firm guidance on a time limit for a second stage of labour, it would be considered good practice to have delivered the baby earlier. Despite the fact that the baby was showing no signs of distress at the time, efforts should have been made to open up a second theatre for Mrs L.
85. Neither the Senior Registrar nor the SHO can remember a figure being put on the likelihood of delivering Mrs L’s baby by forceps, despite Mr L’s contention that an 80% chance of success was mentioned. Whatever was actually said, the length of the second stage of labour in this case should have made the doctors extremely cautious about the chances of delivering the baby by forceps.
86. Prior to the trial of forceps, the Anaesthetic Registrar was asked by the Senior Registrar to commence a Syntocinon infusion that was excessive and not in accordance with the protocol (paragraph 28). I have noted the Trust comments (paragraph 25) that this was a slow infusion, nevertheless this dose was excessive and could have resulted in Mrs L having a tonic uterine contraction, which could have contributed to a lack of blood and oxygen to the baby. It is evident that the protocol was not adhered to and I criticise the Senior Registrar for failing to do so. I also criticise the Anaesthetic Registrar for failing to realise the possible consequences of this excessive infusion at this stage of delivery.
87. The final delay in the second stage of labour occurred as a result of the trial of forceps. The Assessors advise me that after such a long second stage of labour, a forceps delivery, unless anticipated to be straightforward, was not a viable option and that Mrs L should have progressed to Caesarean section immediately. In the event, it was unwise for two attempts at forceps delivery to be made, especially as the first was undertaken by the less experienced SHO, which led to failure and yet more delay. I criticise the Senior Registrar for his management of the trial of forceps.
88. In the light of the Assessors’ opinion that it was unreasonable for Mrs L to have endured such a protracted second stage of labour, I recommend that the Trust’s guidelines be reviewed and rewritten to state that the second stage of labour must not exceed three hours except in exceptional and carefully monitored circumstances. It was also unacceptable that the delivery of Mrs L’s baby was delayed while another patient was receiving attention. A wiser course of action would have been to arrange for the on-call consultant anaesthetist to come into the hospital so that a second theatre could be opened up for Mrs L. I criticise the Senior Registrar for failing to do so.
89. I am satisfied with the labour suite’s handover procedures between midwives and the level of one to one midwifery care that Mrs L received. It would have been a sensible course of action, however, for either the Delivery Suite Manager or the Co-ordinator who took over from her, to enquire about the feasibility of opening up of a second theatre when it became obvious that Mrs L’s delivery would be further delayed through another patient. In view of the length of time that Mrs L had been in the second stage of labour, I consider that it would have been appropriate for either one of them to raise with the Senior Registrar the issue of opening a second theatre, and to have suggested that this should be done. I recommend that there should be guidelines about the necessity of opening a second theatre and that such guidelines should take account of what I have recommended (paragraph 88) in respect of the length of the second stage of labour.
90. Mr L raised a number of other issues concerning his wife’s maternity care. He was concerned about the proper functioning of the equipment used to monitor his wife and baby in the labour suite. I accept the evidence of the Trust that there were adequate supplies of equipment for faulty monitors to be replaced and repaired. A vital issue concerning Mrs L’s labour was that the monitoring of the foetal heart rate was recorded as being satisfactory right up to the point of Caesarean section. However, Mr L seriously doubted that the foetal heart rate was listened to at all after his wife was disconnected from the labour suite monitor for transfer to theatre. Although the Trust have conceded that the batteries of the hand-held sonicaid were low, the second Midwife was convinced that she had heard the foetal heart rate by this means. I have been unable to verify this with any of the available staff present who were accustomed to the general background noise of the theatre, of which the sonicaid was a part. As noted later in this report, there appeared to be no panic or urgency in the theatre between the trial of forceps and the Caesarean section. This would appear to indicate that nothing out of the ordinary was happening at the time. There is no reason to believe that the foetal heart rate was not monitored. I note that for the avoidance of doubt, the practice has since been changed so that the monitor is no longer disconnected but transferred from the labour suite with the patient (paragraph 30).
91. Mr L suspected that the note recording the foetal heart rate following the trial of forceps had been added at a later stage. This is more than likely but does not lead to the conclusion that the entry was falsified in any way. It is often impossible, for practical reasons, for nursing and medical notes to be written up contemporaneously. The only option for Mrs L following the failed trial of forcepswhatever the foetal heart rate readingwas a Caesarean section. There was, therefore, no advantage to be gained in making a false entry and no reason for the second Midwife to have done so.
92. I am concerned that Mrs L should have suffered such extreme anxiety over the issue of whether Baby L had died as a result of infection. She wrongly believed that she or her husband might have caught an infection and might have transmitted it to her baby. It seems that the Consultant Obstetrician reassured Mrs L about this at a later stage, but initially she thought that she was to blame. The Assessors have commented in their report on the poor communication between Trust staff and Mr and Mrs L, and this issue serves to illustrate the point very well. The fact that Mr L was quick to lodge a complaint should not have prevented the Consultant Obstetrician from following his usual procedure for assisting the parents of a stillborn child. Neither should it have been left to the Senior Registrar to see the couple for follow up in outpatient clinic six weeks later. I acknowledge the difficulty such situations present to staff, who are not unaffected by tragedy of this kind. However, I recommend that under such circumstances the parents are invited back as soon as possible to meet the consultant who was caring for the mother during pregnancy. I further recommend that the Trust put in place plans for handling this type of situation better in future.
93. I note that the L case was subsequently discussed at a perinatal audit meeting. In addition, on the advice of the Assessors, I recommend that a multi-disciplinary meeting of all staff involved in such cases should be held to discuss what happened and the lessons to be learned. For the reasons I have identified in the foregoing paragraphs, I uphold the complaint that the management of Mrs L’s labour and delivery was unsatisfactory and inadequate.
Complaint (b) the care provided to Baby L following his birth was unsatisfactory and inadequate
Documentary evidence
94. The Trust’s Clinical Guidelines – Resuscitation, which were current at the time include the following:
‘3. Resuscitation of the newborn infant at delivery
‘3.3.4 White, apnoeic, heart rate ‹60
‘Full cardiopulmonary resuscitation is required. Intubate immediately and commence IPPV (intermittent positive pressure ventilation). If there is no one immediately available who is experienced in intubation, or it is technically difficult, then mask ventilation should be commenced until help arrives. After 30 seconds, re-assess heart rate by ausculation. If heart rate ‹60, commence external cardiac massage (ECM). …
‘If there is no response to IPPV and ECM (external cardiac massage), then a UVC (umbilical venous catheter) should be inserted …
‘A baseline blood gas, BM and full blood count should be obtained.
‘The following drugs should be given:-
a. Adrenaline … b. Sodium bicardonate … c. Adrenaline … d. 10% Glucose …
‘…
‘3.5 Discontinuation of resuscitation
‘If there is no response in the term infant to resuscitation by 20 minutes (ie. the infant has no heart rate and respiratory effort) then resuscitation should be terminated. … Termination of treatment should occur, if possible, after discussion with the parents. In term infants it is important this discussion begins with parents at around 15 minutes, enabling resuscitation to be stopped at 20 minutes. The decision to discontinue treatment should be made by either the Registrar or Consultant: it should not be made by the SHO.’
95. In a letter of 12 July 2000 to the Ombudsman, a Consultant Neonatologist at the Trust wrote:
‘The new Resuscitation Policy was introduced into the Neonatal Service in January 1997. As part of this policy new guidelines were developed for basic life support and advanced life support. These were made into flow charts which were laminated and placed on all resuscitaires (resuscitation trolleys). I cannot tell you the exact date that these were placed on the resuscitaires but we believe that it would have been no later than March 1997. At the same time, a chart was also made which described all drug doses based on weight to be used during neonatal resuscitation. Again, laminated copies were attached to all resuscitaires. …’
Trust evidence
96. The Anaesthetic Registrar said that he had had experience of working in paediatrics but had not held a neonatal post. He remembered this case very well because it had been his first involving foetal death. Although not in a position to give an opinion on the Caesarean section, the Anaesthetic Registrar could not recall the procedure as having been other than routine. He was not aware of any panic from the midwives and obstetricians at the time and Mrs L had been comfortable throughout.
97. The Anaesthetic Registrar explained that the usual sequence on delivery was for the baby to be passed to the midwife, or the Paediatric SHO, for examination. Baby L was passed to the Paediatric SHO who encountered difficulty ventilating him with a facemask. She made several unsuccessful attempts at intubation before the Anaesthetic Registrar was called to assist. Since his primary responsibility was to his patient, he ensured that Mrs L was stable and allocated a nurse to watch her before joining the Paediatric SHO. Baby L had no apparent cardiac output and neither of them could feel his pulses. At two minutes after delivery the Anaesthetic Registrar attempted to intubate him. When he was unable to do this with a paediatric tube, a straight tube of the type used by Anaesthetists was urgently obtained. Meanwhile he bagged and masked the baby and obtained chest movement as the Paediatric SHO performed external cardiac massage. They worked together and while the Anaesthetic Registrar made it his responsibility to work out the drug doses, he thought that the Paediatric SHO had probably administered them. Adrenaline was prepared and given via the tube as there was no intravenous access at that stage. Atropine was then administered and a further dose of adrenaline given intravenously. The Anaesthetic Registrar could not recall whether any blood gases had been taken and there was nothing noted in the medical notes. External monitoring was applied to Baby L while waiting for the urgent arrival of the Paediatric Registrar. There were, however, no spontaneous respiratory efforts or movements from the baby at any stage.
98. The Anaesthetic Registrar handed over to the Paediatric Registrar after he arrived in theatre and returned to Mrs L. There had been no prior indication of the need for the Paediatric Registrar to be present for the delivery and the sequence of events had been entirely unexpected. The Anaesthetic Registrar had no further debriefing or discussion with the doctors about this case and was content with this situation as there had been no problem from an anaesthetic viewpoint. He visited Mrs L an hour later on the postnatal ward and she was reasonably happy with the mode of anaesthetic chosen for the delivery.
99. The Paediatric SHO said that she had been bleeped to go to theatre by Mrs L’s midwife, to attend a trial of forceps that might lead to a Caesarean. She was told that the baby was full term and the reason for the trial of forceps was a delayed second stage of delivery. There were no factors indicating that the baby was in distress and it was considered a routine case. In more concerning circumstances the Obstetrics Registrar would discuss the case in more detail and the Paediatric Registrar might be asked to attend. The Paediatric SHO had no particular memories of the trial of forceps or of any monitoring problems. Although she could not remember hearing a sonicaid, she was quite sure that there was no problem with the CTG between the trial of forceps and the Caesarean. Specifically, there was no alarm or sense of unusual urgency in the theatre.
100. The Paediatric SHO said that she was responsible for the resuscitation of any baby who had a problem following delivery. In the case of Baby L, he was born completely floppy with no signs of life. There was no heart rate, no response, and he was white rather than blue. She initially felt for a pulse on the chest and listened with a stethoscope for about five seconds. Having found no pulse, her next step was to intubate the baby. She had done in excess of 15 intubations at the time and was confident of doing the procedure. She attempted to intubate him once and was surprised and horrified that she did not manage to get the tube in the right place. She had previously dealt with one or two complex resuscitations but none had involved a baby as flat as Baby L. The Anaesthetic Registrar came over and offered to help and was successful on his second attempt. The Paediatric SHO gave chest massage and asked someone to bleep the Paediatric Registrar. She could not remember the precise time that this had happened or much about the delay in him gaining access to the theatre. The theatre doors were locked but usually left open if a case was being dealt with. Staff could get in round the back and she thought this might have been the way in which he had gained entry.
101. The Paediatric SHO said that she had worked out the dose of adrenaline for the baby and that it had been her decision to administer it. The first dose had been given by the time the Paediatric Registrar was on the scene and the baby was receiving chest compressions. The second dose was probably given after the Paediatric Registrar’s arrival following which he took charge, working out and administering further doses of drugs. The procedure was to continue the resuscitation attempts while one of the staff put ECG (electrocardiogram) leads on the baby to monitor him. No pulse was felt or heard and the heart rate on the monitor was very low. They continued their efforts and then the Paediatric Registrar asked someone to contact the Consultant Paediatrician. The Paediatric Registrar informed him of the situation and spoke to him again about 30 to 40 minutes post delivery when he advised that resuscitation could be stopped. The case had been discussed at a subsequent informal meeting to piece together what had happened and to try to make sense of it. However, they had been unable to ascertain what the problem had been or what had gone wrong.
102. The Paediatric Registrar works abroad and could not be interviewed for this investigation. Extracts from his notes include the following:
‘… 19/04/97 Crash call to theatre (2 minutes after delivery) for resuscitation of baby. Born by [emergency] LSCS (Caesarean section)– NO SIGNS OF LIFE after delivery. Arrived at 4 minutes. Baby was already intubated at 2 minutes and was given ECM (external cardiac massage). 2 lots of Adrenalin via ET tube. … at 15 minutes (Informed Consultant Paediatrician) … Spoke to [Consultant Paediatrician] at 40 minutes and he advised to stop resuscitation. … tube removed and UVC removed … spoke to Mum/Dad – mentioned that there were no signs of life at delivery – obtained permission for P.M. Δ [diagnosis] Stillborn …’
103. In a written response to the Ombudsman, the Consultant Paediatrician said that he could not remember being informed about Baby L by the Paediatric Registrar; he was therefore unable to say what he had been told or what advice he had given. However, he always came into the hospital if asked to do so and in an emergency could be there in 20 to 30 minutes. His role in such a situation would be to assess the baby who had been resuscitated, or to talk to the parents of the baby who had died.
104. The Consultant Paediatrician outlined the procedure in similar cases to that of Baby L. If resuscitation attempts failed, the paediatric registrar involved would inform the consultant paediatrician by telephone. In most instances, the paediatric registrar would be seeking permission to stop resuscitation. In Baby L’s case, the Consultant Paediatrician’s examination of the clinical records showed that this had been done. The Paediatric Registrar had telephoned after resuscitation attempts had continued for 40 minutes after delivery, and had been advised to stop. They would have discussed together the details of the resuscitation the following day but this would not have been recorded in the notes. It was clear, however, that Baby L had been born without signs of life and that resuscitation had been unsuccessful in spite of prolonged, vigorous efforts.
105. In interview with the investigating officer, the Delivery Suite Manager outlined the improvements to practice that had been put in place in the wake of this case. The door of the operating theatre was no longer locked, as it had been on the day in question, and staff carried swipe cards that allowed immediate entry whilst preserving security. With regard to sonicaids, a new rechargeable type was now in use.
Findings (b)
106. Once again I have been guided by the advice of the Assessors in making these findings. The evidence is that Baby L was a fresh stillborn, indicating that he died shortly before delivery. Sadly, therefore, there was no prospect that resuscitation attempts would succeed and they were terminated, on the advice of the Consultant Paediatrician, 40 minutes after delivery. There is no evidence that Mr and Mrs L were brought into a discussion with the medical staff about the course of resuscitation and its eventual discontinuation. This would have been desirable but not perhaps possible in this case, given the suddenness and unexpected nature of events and the ongoing efforts to resuscitate Baby L.
107. I am advised that it was reasonable for the Paediatric SHO to accept the assistance of the Anaesthetic Registrar to intubate Baby L when she herself experienced difficulty with the procedure. Both doctors continued to work together until the Paediatric Registrar arrived. However, they did not follow the protocol for neonatal resuscitation which was displayed on all resuscitaires (paragraph 94). I am advised that the drug doses given were correct but that the protocol does not include the administration of atropine. Venous access and the administration of sodium bicarbonate were performed at a later stage than recommended by the protocol, and blood was not taken for blood gas, full blood count and glucose estimation. The Ombudsman’s Assessors point out that these failures to follow the resuscitation protocol did not alter the outcome for Baby L, but might do so in other cases. I therefore conclude that the staff involved would have benefitted from detailed feedback in relation to their resuscitation attempts and recommend this is done in such cases in future.
108. It appears that the Paediatric Registrar was called promptly but was delayed getting into the theatre because of locked doors and had to enter via the back. I welcome the Trust’s subsequent introduction of swipe cards which allow medical staff immediate access, while maintaining the security of the theatre.
109. The Ombudsman’s Assessors consider that the current arrangement whereby one Paediatric Registrar is responsible for covering both paediatrics and neonatology, is a significant risk management problem. The Paediatric Registrar’s attendance in theatre could have been seriously delayed if he had been at another location in the hospital. As has already been established, this would not have altered the outcome for Baby L but, in other circumstances, this practice could mean the difference between life and death. I strongly recommend therefore that the Trust consider the provision of two Paediatric Registrars to cover the two areas of paediatrics and neonatology. Baby L was stillborn, however, and sadly there was no paediatric care that could have altered that situation. However, in view of the departure from established protocol that I have identified above (paragraph 107), I uphold the complaint to that limited extent.
110. Mr L has suggested t | 
