Coroner: Baby's death at NHS Trust due to neglect

A baby who died from a brain injury following a delayed labour and delivery was failed by staff at Sherwood Forest Hospitals NHS Trust, a Coroner has concluded.

Arlo River Phoenix Lambert died on 9 March 2023 at Kingsmill Hospital, Nottinghamshire, at five days old. The Coroner found that Arlo’s death was “contributed to by mismanagement of labour and multiple missed opportunities to have expedited his delivery.”  

She concluded that neglect contributed to Arlo’s death, which came from “a failure to follow Trust guidance.”

Miss Lambert, Arlo’s mother, was induced at 40+2 weeks, and following spontaneous rupture of membranes (SROM), she was left for 17 hours without any attempts made to progress her labour.  The Coroner found that this allowed the risk of infection to materialise. During that time, staff failed to properly review Miss Lambert’s care plan and discuss modes of delivery with her when concerns were raised about the position of the baby and her labour was failing to progress.  

The Coroner found evidence of “multiple missed opportunities to have expedited Arlo’s delivery, which would probably have prevented his death.” She has issued a Prevention of Future Deaths Report. 

Since Arlo’s death, Miss Lambert has suffered from post-traumatic stress disorder (PTSD).

Furthermore, the coroner also made a complaint to the General Medical Council regarding the actions of Specialist Registrar Dr Adeyemi. In oral evidence, he said that he would “cross [my] fingers behind my back and hope and pray the mother would go into labour” instead of implementing an appropriate care plan.

A post-mortem autopsy found that Arlo’s brain showed evidence of hypoxic-ischaemic injury. This is where brain cells die because of a period of time spent without adequate oxygenated blood supply, which can occur as a result of delayed delivery following fetal distress. 

The Coroner found an abundance of issues with the pre-natal care of Miss Lambert between her induction of labour at 17:15 on 2 March 2023 and Arlo’s birth at 04:26 hours on 4 March 2023.

Even before then, Miss Lambert faced failings in her antenatal care. At 38+6 weeks gestation, she attended the hospital for a growth scan. At this point, she was offered induction of labour at 40+2 weeks due to some concerns about the growth of the fetus. This course of action was outside the national definition for slowing fetal growth, and induction of labour was not indicated, but “there is no evidence” that Miss Lambert was made aware of that fact, the Coroner concluded. 

If Miss Lambert had not been offered induction of labour at 40+2 weeks, she would likely have gone into labour spontaneously, the Coroner stated, and “her previous labours suggest she would not have faced any challenges delivering Arlo.”

When she arrived under the care of Sherwood Forest Hospitals NHS Trust, numerous delays in commencing the induction led to the tragic outcome.

Poor communication and a staff shortage contributed to delays in developing a delivery plan. 

At 11.33 hours on 3 March 2023, the baby’s head was found to be presenting high in the pelvis. Still, there was a missed opportunity to consider the mode of delivery and to have counselled Mum on the risks and benefits of continuing with induction of labour, or caesarean delivery, in accordance with national guidance, the Coroner found. At this point, CTG monitoring was discontinued, which was also against national guidance, so the midwives were unable to monitor for any signs of fetal distress continuously.

At 17.00 hours, after being asked to confirm the position of the fetus with an ultrasound scan, it was Dr Adeyemi who wrote a delivery plan without consulting Miss Lambert’s wishes and, without having full knowledge of her situation and without reviewing her clinical records.

If the induction of labour policy had been followed when labour was not established two hours after SROM, delivery by either method “would probably have avoided his death”, she concluded.

Moreover, at the ward round at 21.43 hours, there was a communication failure between the midwife and obstetric team to understand that there had been blood-stained liquor, which again led to a missed opportunity to consider the mode of delivery.

It wasn’t until 03.58 hours on 4 March that doctors decided to proceed to a category 1 caesarean section for suspected placental abruption. 

At just before 04.30 hours, Baby Arlo was delivered by a difficult caesarean section due to his position, following a delay by the midwives recognising that there were complications and alerting the obstetric team for assistance. Baby Arlo was in a compound position with a leg and an arm above his head. 

It was apparent on delivery that there had been a placental abruption, given the volume of blood and clot within the uterus. Arlo was transferred to the neonatal unit at the Queen’s Medical Centre for specialist care, but he sadly passed away five days later.

Specific failings highlighted by the Coroner include the staff’s failure to follow the Trust’s induction of labour policy to augment labour (by administering a hormone drip to bring on contractions) if it is not established within two hours after SROM for a multiparous mother. 

Had Arlo been delivered sooner, he “would more likely than not have survived,” the Coroner concluded.

Following a series of high-profile scandals in recent years, NHS Trusts are under pressure to improve services. A recent Birth Trauma Inquiry found that poor maternity and postnatal care is “tolerated as normal” and called for an overhaul in the face of overwhelming evidence of medical negligence.

Chantae Clark of Tees Law, acting for the family, said: “These tragic events were preventable if Sherwood Forest Hospitals NHS Trust had followed the guidance and acted on the warning signs in the hours before Miss Lambert’s labour. It is hard to believe that in such an advanced healthcare system, a mother should suffer the treatment that she did and that a baby should die because of neglect. 

The immense toll on Arlo’s family shows the devastating impact of these failings. It is of some comfort to the family that the Coroner has carried out such a robust investigation and has found evidence of neglect and issued a Prevention of Future Deaths Report. The family sincerely hopes that the Trust implement urgent changes to prevent another avoidable disaster from befalling any other family.” 

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