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.
Coroners findings on contributing factors
The Coroner concluded that neglect contributed to Arlo’s death, citing a “failure to follow Trust guidance.”
Miss Lambert, Arlo’s mother, was induced at 40+2 weeks. After a spontaneous rupture of membranes (SROM), she was left for 17 hours without attempts to progress her labour. The Coroner found that this delay allowed the risk of infection to materialise. Staff also failed to properly review her care plan or discuss delivery options when concerns arose about the baby’s position and the lack of labour progression.
Missed opportunities and preventable death
The Coroner identified “multiple missed opportunities to have expedited Arlo’s delivery, which would probably have prevented his death.” A Prevention of Future Deaths Report has been issued.
Since Arlo’s death, Miss Lambert has experienced post-traumatic stress disorder (PTSD).
Complaint against specialist registrar
Additionally, the Coroner made a complaint to the General Medical Council regarding the actions of Specialist Registrar Dr Adeyemi. In oral evidence, he stated that he would “cross [my] fingers behind my back and hope and pray the mother would go into labour” rather than implementing an appropriate care plan.
Evidence of brain injury
A post-mortem autopsy confirmed that Arlo’s brain had suffered a hypoxic-ischaemic injury, caused by a lack of adequate oxygenated blood supply. This was attributed to the delayed delivery following fetal distress.
Failings in antenatal and labour care
The Coroner found significant issues in Miss Lambert’s care between her induction of labour on 2 March 2023 and Arlo’s birth on 4 March 2023.
Antenatal failings
At 38+6 weeks gestation, Miss Lambert underwent a growth scan and was offered induction at 40+2 weeks due to concerns about fetal growth. However, the Coroner concluded that this decision was outside national guidelines, and Miss Lambert was not informed that the induction was unnecessary. The Coroner stated that she would likely have gone into spontaneous labour without complications.
Labour management failures
Upon Miss Lambert’s admission, numerous delays in commencing the induction occurred, exacerbated by poor communication and staff shortages.
At 11:33 on 3 March, a high fetal head position was noted, presenting a missed opportunity to consider a delivery plan. Additionally, the decision to discontinue CTG monitoring, against national guidance, prevented the detection of fetal distress.
By 17:00, Dr Adeyemi formulated a delivery plan without consulting Miss Lambert, reviewing her records, or considering her preferences.
The Coroner concluded that had the Trust’s induction of labour policy been followed, and delivery occurred within two hours of SROM, Arlo’s death could have been avoided.
Delayed caesarean section and birth complications
At 21:43, a further opportunity was missed when blood-stained liquor was reported. A lack of communication between the midwife and obstetric team meant that the mode of delivery was not reconsidered.
Doctors eventually opted for a category 1 caesarean section at 03:58 on 4 March, following concerns of placental abruption. At 04:26, Arlo was delivered via a difficult caesarean, with evidence of a placental abruption. Despite specialist care at the Queen’s Medical Centre, he died five days later.
Specific failings identified by the Coroner
The Coroner outlined the following key failings:
- Failure to follow the Trust’s induction policy.
- Inadequate monitoring of fetal distress.
- Poor communication and staff shortages.
- Lack of consideration for Miss Lambert’s informed consent.
Had Arlo been delivered sooner, the Coroner concluded that he “would more likely than not have survived.”
Calls for maternity care reform
Following a series of high-profile scandals, NHS Trusts face mounting pressure to improve maternity care. A recent Birth Trauma Inquiry condemned poor maternity and postnatal care as “tolerated as normal,” calling for systemic reform.
Family’s response and legal representation
Chantae Clark of Tees Law, representing the family, stated:
“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.”
She emphasised the emotional toll on Arlo’s family and expressed hope that the Coroner’s findings and Prevention of Future Deaths Report will lead to meaningful changes in NHS maternity care.
