Inquest Into Infant's Death Delivers Narrative Verdict

By Ashlea McConnell

The father of a baby who died after being starved of oxygen when midwives failed to notice he had been born under bed sheets has today spoken of his grief and anger after waiting four years for an apology and an admission of fault from the Trust responsible for his son’s care.

Maninder Singh was born on October 23rd, 2008 at St Mary’s Hospital in Manchester following a harrowing labour during which mum Geeta, who suffered from diabetes, had opted for a epidural – leaving her unable to feel anything from the waist down.

When Maninder was delivered medical evidence suggests he was already in a poor condition, but the delay in staff noticing and acting to resuscitate him meant he suffered further, avoidable injury. He remained in the intensive care unit throughout his life and passed away on May 4th, 2009. 

Medical law experts at Irwin Mitchell representing the family say that an internal investigation carried out following the tragedy by the Central Manchester University Hospitals NHS Foundation Trust found midwives had repeatedly failed to check Geeta’s progress or effectively monitor the baby’s heart rate.

And at a one day inquest into Maninder’s death concluding today, Manchester Coroner Mr Meadow’s recorded a narrative verdict.

But despite the internal investigation, which concluded in July 2009, identifying a number of key failings in the care his wife and son received Maninder’s father, Kamaljeet, received an apology only yesterday. An apology he says lacked remorse, accusing the hospital of carrying out a ‘damage limitation’ exercise.

The family’s lawyer, Sharon Williams from law firm Irwin Mitchell’s Manchester office, went on to call the delay ‘unacceptable and unnecessary’.

She said: “The internal investigation clearly flagged failures in the care received by Mrs Singh from the very moment she was induced until Maninder’s delivery some eight hours later. He was born with significant brain injuries and later died as a result. 

“But despite this evidence being available from July 2009 an admission of liability was only issued on April 5th this year – nearly four years on. Furthermore, it was only in this letter of admission that the Trust expressed an intention to apologise to the family for the first time.”

Tragically, this apology comes too late for Geeta Singh who died of multiple organ failure, septicaemia and diabetes just months after the birth of the couple’s second child in January 2010.

The 32-year-old was referred to St Mary’s Hospital on Oxford Road during her pregnancy for specialist support given her numerous health conditions – including diabetes and anaemia.

A decision was made to induce her at 34-weeks amidst concerns that the baby’s growth had slowed. But midwives did not regularly check Geeta’s labour progress and acceleration in dilatation saw her deliver Maninder whilst numb from the recent administering of an epidural.

When midwives went to attach a fetal scalp electrode in an attempt to better monitor the baby’s heart rate they realised that Maninder had been born, and starved of oxygen. He was later diagnosed with a serious brain injury from which he died six months later.

An internal investigation concluded that staff:

• Failed to communicate effectively during handovers
• Failed to fully acknowledge and respond to Geeta’s medical needs
• Failed to properly and regularly assess the progress of labour

A number of recommendations were made following the investigation including the decision not to administer spinal anaesthetics without a vaginal examination, and the importance of all medical staff seeing ‘high risk women’ during routine ward rounds. 

Now Maninder’s family are calling for assurances that the recommendations were acted upon, and that lessons learnt following the tragedy have been shared across the NHS in a bid to ensure no one suffers in the way Geeta and Maninder did going forward.

Kamaljeet from Urmston, Manchester, said: “This has been an extremely difficult four years for my family who lost a much loved son under horrific circumstances.

“I am pleased that we finally have justice, and that the Trust has admitted that more could have been done to save Maninder, but it has been four years and this apology is too little too late. My wife died never knowing what happened and why and never knowing that anyone was sorry for our loss.

“To us, it feels more like a damage limitation exercise rather than a genuine expression of remorse and I only hope that lessons are learnt across the NHS so that no one should suffer the way we have going forward.”

Sharon Williams from Irwin Mitchell went on to call for a clear explanation of why there has been such a delay in the admission of fault, and apology to the family from the Trust, in light of the findings of the investigation almost four years earlier.

She said: “To lose a child is heartbreaking enough, but to have to fight for so long and so hard to simply receive acknowledgment and an apology from those responsible that more could, and should, have been done, is just unacceptable.

“We want assurances that lessons have been learnt from the failings identified in the Trust’s own investigation, clarity as to why there have been such delays in admitting fault and an apology to be made to the family not only for their loss, but for any additional heartache they have endured during this process.”

In a letter to Mr Singh the Manchester Trust's chief executive, Mike Deegan, wrote “I would like to sincerely apologise to you for the failure to adequately monitor Maninder’s heart during labour and to express our profound regret for Maninder’s death”.

 Read more about Irwin Mitchell’s expertise related to medical negligence claims