Medical Negligence Lawyers Instructed Following Death Of Newborn On New Year’s Day

A Leeds couple have spoken of their determination to ensure improvements are made to maternity services after their baby daughter died shortly after birth following “neglect by midwives.”

Fiona Winser-Ramm, then 34, was 41 weeks into her first pregnancy when she was booked in for an induced labour.  On the day of the induction, whilst she was still at home, contractions began spontaneously. Fiona was advised by the maternity assessment centre (MAC) at Leeds General Infirmary that she could remain at home. 

Mum raises concerns over baby's movements

Contractions continued and the following morning, Fiona telephoned the MAC and reported discharge.  She also said she was concerned about her baby’s movements and that her waters may have ruptured, however she wasn’t offered the opportunity for an assessment at that time.

The next day, contractions had increased in strength and frequency and Fiona was admitted to Leeds General Infirmary.  After an initial assessment and admission to the delivery suite, she was examined again and the baby’s heart rate was categorised as pathological or abnormal, using a Cardiotocograph (CTG).  Observations continued and, shortly afterwards, the baby’s heart rate improved and was recorded as normal.  However, during the last four hours of labour, the baby’s heart rate deteriorated again.

During the early hours of New Year’s Day, 2020, Aliona was born in a poor condition.  She was unable to be resuscitated and was pronounced dead, aged 27 minutes.

Couple instructs medical negligence lawyers to investigate care

Following their daughter’s death, Fiona, now 37, and her husband Daniel, now 40, contacted AvMA (Action against Medical Accidents; the UK charity for patient safety and justice) and were directed to medical negligence experts at Irwin Mitchell to help establish answers and provide support through the inquest process.  The legal experts are also investigating the care provided to Fiona and Aliona by the Leeds Teaching Hospitals NHS Trust, which runs Leeds General Infirmary.

An inquest was held at Wakefield Coroner’s Court in December 2022.

Inquest finds "a number of gross failures" contributed to baby's death

It concluded in February 2023 that there were “a number of gross failures of the most basic nature that directly contributed to Aliona’s death.”  Coroner Janine Wolstenholme stated that “on 30 December 2019, there was a spontaneous rupture of Aliona’s membranes with meconium” which “required medical assessment, however midwives did not act upon this information and admission to hospital and induction of labour was delayed.”

She went on to say that following Fiona’s admission to hospital, Aliona’s heart trace became “concerning and mandated escalation to a doctor for a medical review.”  However, “neglect by the midwives led to delays in escalation and in turn an overly prolonged second stage of labour.”  Aliona was born in a “poor condition” and her “injuries proved unsurvivable.”

It was heard that Fiona and Daniel “were not given any or adequate information about induction of labour and potential intervention prior to 29 December” which Coroner Wolstenholme found to be “extremely poor practice” and a “gross failure in care.”

To not take into account Aliona’s rising baseline heart trace and notice “markedly concerning features” was also identified as a “gross failure in basic care.”  Furthermore, if Aliona’s care had been escalated to doctors, as it “ought to have been”, by no later than 11.30pm, “doctors would have been aware of the progress, or lack, of and delivery would have been expedited before it was and Aliona would not have died when she did.”

Hospital Trust apologises for "substandard care"

This comes after the Hospital Trust admitted, through NHS Resolution, a “failure to appreciate the high risk nature of the pregnancy and recognise the CTG abnormalities over a prolonged period of time were responsible for the poor outcome”.  It added that “earlier intervention would have, on the balance of probabilities, resulted in a live birth” and apologised for the “substandard care” Fiona and Aliona received.

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“Understandably, losing Aliona and trying to understand how her death came about has been incredibly difficult for Fiona and Daniel. They were so excited to welcome their baby girl into the world. They remain devastated by her death.

“For three years since Aliona’s death, they also had a number of concerns over what happened in the lead up to Aliona being delivered. Throughout their investigation into what happened, their primary concern and goal has been to understand what happened and ensure that other families do not have to go through the same experience.

“Nothing can change what Fiona and Daniel have been through and facing everything again at the inquest has been tough, but we’re pleased we have been able to help provide them with the answers they deserved; answers that validated the concerns they had regarding the care they received.

“Sadly, worrying failings have been highlighted in the care provided to Fiona and Aliona. While we acknowledge the Trust’s admissions, it’s now vital that lessons are learned to improve maternity safety.

“We’ll continue to support Fiona and Daniel at this distressing time.” Katie Warner, Medical Negligence lawyer

The inquest also heard a number of the midwives involved in Aliona’s care were shown excerpts of her CTG trace, and all admitted, upon looking over them again, that they should have categorised it as pathological, necessitating urgent escalation.

Parents should be informed of the CTG categorisations when they’re checked every 30 minutes, however the inquest heard that these hadn’t been communicated by the midwife to Fiona and Dan, despite the midwife recording in the medical notes that they had. If they had been informed, the couple would have insisted on action being taken.

It was found that the same midwife had tried to raise concerns about the CTG to the midwife in charge of the delivery suite but the inquest heard that the midwife in charge admitted she thought she had time to wait for the registrar on shift who was with other patients at the time so failed to immediately escalate the concerns to the on-call consultant.

Investigation leads to a number of safety recommendations

Following Aliona’s death, an investigation was carried out by the Healthcare Safety Investigation Branch (HSIB) with a number of safety recommendations made.

These include the Hospital Trust ensuring that mothers are offered a “face-to-face assessment” in line with local and national guidelines when labour is suspected, and there is “timely escalation to the obstetric team when there are concerns regarding fetal heart rate monitoring.”

Furthermore in the second stage of labour, when a mother is high-risk, she should be “risk assessed and decisions about management are made in partnership with the obstetric team,” the report said.’  It also recommended that continuous risk assessments are carried out during the labour, along with regular obstetric reviews.

Aliona’s parents also reported being told by hospital staff that they did not know why Aliona had died in the days that followed her death.  However, the inquest heard that the Head of Maternity Services accepted that staff were aware, within 24 hours, that there had been problems with Aliona’s CTG and staff had not taken appropriate action when it was required.

Fiona and Daniel's story

Fiona said: “At the moment we were told Aliona had died, our world imploded.  What was meant to be the happiest day of our lives catastrophically descended into the worst.”

“The staff at the hospital had our utmost trust and respect; never once did we think we would be faced with having to leave without our baby girl.  Our lives are completely ruined.  I still wake up every morning and just think for a second that my life is normal, before the sledgehammer of reality hits.  I feel like a piece of me is missing.”

She continued: “Since becoming a part of the baby loss community, we’ve spoken to so many other parents in Leeds who have been through similar trauma and the ordeal of finding out they received substandard or inadequate care.  It’s truly awful and more needs to be done to prevent it happening again and again.

“While we can’t change what’s happened, I hope that by sharing our story we can empower others to question their care or ask for a second opinion.  We deserved to be informed of any concerns around Aliona’s wellbeing and progress during labour, so I would urge other parents-to-be to trust their instincts and challenge anything they’re unsure about.

“We’re incredibly grateful to our legal team and to the coroner for listening to us and validating everything we’ve said for the past three years.  Unfortunately, however, it won’t bring our beautiful little girl back and we will continue to grieve for her and the life we should be living.”

Dan added: “Some of the changes that have been recommended seem to be common sense and just basic care, and we believe that these should have already been happening.”

“Since that day, we’re no longer the people we want to be.  Our whole experience could, and should, have been so different.”

Baby Loss Awareness Week runs from 9 to 15 October 2023.

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