Coroner set to ask for more information into death of baby at Telford hospital

West Mercia Police launched an investigation into the death of baby Poppy Mary Isabella Russell at the PRH on April 11, 2021.

It was part of Operation Lincoln, which was set up to establish whether there is evidence to support a criminal case against Shrewsbury and Telford NHS Hospital Trust or any individuals involved.

Shropshire coroner John Ellery, at a pre-inquest review at Shirehall, Shrewsbury, yesterday, said the Crown Prosecution Service had considered that Poppy’s death 11 hours and 50 minutes after her birth “had not met the threshold for a criminal prosecution”. The parents of Poppy were taking part in the proceedings online and challenged that, but after a short adjournment the police were able to confirm that Mr Ellery’s understanding of the issue was correct.

Mr Ellery said Poppy had died after suffering complications with her breathing at or around the time of delivery. He said it had taken two years to reach the stage of a possible inquest because there had been separate investigations, by the Healthcare Safety Investigation Branch (HSIB), and the police.

The HSIB looks into factors in maternity that have harmed or may harm NHS patients and works with patients, families and healthcare staff, and the organisation says it never attributes blame or liability. Mr Ellery said that the HSIB report had found areas of concern.

He said he had to consider whether to open an inquest based on whether baby Poppy had died of natural causes or there had been an unnatural element. He said his decision is based on a “balance of probability”, rather than the evidence needed for a criminal investigation.

Mr Ellery said the issue is whether he should duplicate the HSIB’s work and yesterday he invited legal representatives of the Shrewsbury & Telford Hospitals NHS Trust to have their say.

Laura Weir, an associate solicitor with Lanyon Bowdler, representing the family, asked to see the evidence used in the HSIB report.

Mr Ellery said his coroner’s officer Michael Caesar-Homden had been told by the HSIB that it “could not voluntarily provide the information” and that it needed him to lodge a ‘schedule five’ notice with them. The HSIB, he said, could then provide the information, or give a reason why they could not.

Mrs Weir said: “It is sensible to ask for the reports, any dispute will come from that.” Victoria Davies, a solicitor representing SaTH said: “A step-by-step process is the most logical way forward.”

A representative of the Care Quality Commission was also observing online proceedings.

Mr Ellery decided that on Monday he would send a schedule five notice to the HSIB and have the information sent to the trust and the family. A further expert analysis may also be required. He agreed to review the case again at a date in March which will be decided.