Shropshire Star

Shropshire baby death prompts calls for changes by coroner

Hospital chiefs have been told by a coroner to make improvements to avoid more baby deaths after a four-month old collapsed and died following complications at birth.

Published

Shropshire coroner John Ellery has written to the trust in charge of Shropshire's two main hospitals saying he believes they can make changes to avoid future deaths.

Ivy Morris died at Royal Shrewsbury Hospital in May after collapsing during a feed at the family home in Oswestry while suffering from bronchopneumonia.

Her inquest heard that errors during her birth including monitoring the wrong heartbeat and a delayed second stage of labour meant she suffered from severe perinatal hypoxic ischaemic brain damage.

Ivy was born in December last year at Princess Royal Hospital in Telford with life-limiting needs after suffering from hypoxia – a lack of oxygen reaching the tissue.

The machines which were supposed to be monitoring her heartbeat during labour were in fact picking up on the heart rate of her mother, the inquest heard. There was also a delay in the second stage of labour. This meant it would not be possible to identify an abnormal heart rate in Ivy during her birth.

Mr Ellery has now written to Simon Wright, chief executive of Shrewsbury and Telford Hospital Trust, outlining three areas of concern.

He said: "Ivy's foetal heart rate ought to have been monitored and was not monitored. In the second stage of labour the maternal heart rate was recorded on the external CTG machine for the majority of (if not all) the time when the intent was to monitor the foetal heart rate.

"The confounding factor was the similarity of the heart rates at the commencement of the second stage. There were opportunities and methodologies available to resolve this issue that were not taken."

The coroner also expressed concerns about the failure to follow midwifery guidelines surrounding verifying the CTG readings and getting obstetric opinions during labour.

The trust now has 56 days to respond to the coroner's concerns, saying what action has been taken or is proposed to be taken and how long these changes could take.

Shrewsbury and Telford Hospital Trust apologised to Ivy's parents following her inquest last month. Speaking after the inquest, Ivy's mother Tamsin said:

"Our lives have been changed forever and no outcome from the inquest will bring Ivy back to us."

Sorry, we are not accepting comments on this article.