Coroner Calls For National Review Of Consultant Attendance At High Risk Deliveries

The distraught parents of a baby who died just half an hour after birth at Ipswich Hospital say they hope lessons are learned after an inquest heard there were several errors with care provided during the birth.

Emma Strachan, 29, from near Framlingham, went into spontaneous labour in January this year with a plan to deliver her baby in the breech position. However, after a delay in delivering the head, her baby girl Bonnie May was born in a very poor condition. Tragically, Bonnie did not respond to efforts to resuscitate her and staff were unable to save her.

The devastated parents, Emma and James Strachan, 37, instructed specialist medical negligence lawyers at Irwin Mitchell’s Cambridge office to investigate the care provided during the birth and to represent them at the Inquest which was held at IP City Centre, 1 Bath Street, Ipswich on 29 and 30 September 2015.

HM Coroner for Suffolk, Dr Peter Dean, returned a narrative conclusion that Bonnie died from complications following a prolonged final phase of breech delivery, that the presence of a consultant at delivery would have led to an earlier delivery on the evidence and that the immediate prospects of survival would have been improved but whether the ultimate outcome would be successful could not be established.

Significantly, Dr Dean took the unusual step of making a Prevention of Future Deaths Report, declaring that he would be writing formally to the Chief Medical Officer to ask her to consider the issue of the need for consultant obstetricians to attend high risk deliveries. 

Earlier in the hearing Dr Dean had heard evidence that the doctor undertaking the delivery had experience of only two previous breech deliveries independently and the on-call consultant was not asked to attend to assist her.

When difficulties were encountered in delivering the head, there were delays in instituting the correct manoeuvres to deliver the arms and head earlier.  Tragically, by the time Bonnie was born she had been profoundly starved of oxygen and efforts to resuscitate her were stopped after 29 minutes. 

Guy Forster, a Partner in the expert medical negligence team at Irwin Mitchell representing the family said:

Expert Opinion

“It is clear from the evidence heard these last two days that the Strachan family have been very badly let down. The family will always believe that Bonnie’s death was completely avoidable.

“In hindsight Bonnie was such a big baby that, according to national guidelines, a breech delivery was never advisable. The family feel that opportunities to recognise Bonnie’s size earlier on were missed.

“Bonnie’s parents had opted for a breech delivery on the understanding that there would be an obstetrician experienced and skilled in the management of vaginal breech deliveries who would be able to deal with any complications that arose. Sadly, that did not happen.

“By her own admission the doctor involved was neither sufficiently skilled nor experienced in breech deliveries. When it came to it, the doctor failed to insist that the consultant attended and there was a substantial delay in delivering Bonnie’s head. The family feel that this lack of clinical judgement and the inexperience of the registrar have cost them their baby daughter.” Guy Forster - Partner

Emma’s first pregnancy with son, Percy, had been consultant-led and this was considered for Bonnie too but it was decided this was not necessary until the later stages until Bonnie was found to still be in a breech position.

The couple had taken the opportunity to ask questions of the consultants about relative benefits and risks of a vaginal breech delivery over a caesarean section. They asked about the size of their baby as they were concerned as to whether this would make a breech delivery more difficult but no measurements of their baby were taken.  

Although Emma and James discussed the options for a breech baby they feel the risks of a vaginal birth were not fully explained and felt the consultants were clearly in favour of this over caesarean. They say they were never made aware that anyone other than a consultant experienced in breech deliveries would be delivering their baby.

Emma said: “Our baby girl was taken from us and Percy’s little sister was taken from him. The whole situation has affected us all physically, emotionally and socially. The entire family has also suffered and we are effectively taking it in turns to support each other.

“We feel like our world has been turned upside down and we are still trying to find our feet. Nothing can turn back the clock for us now but we can only hope that they learn from this so that others don’t suffer in future. We wanted to do everything we could to prevent this from happening again and instigate real change. 

“We are aware that the Trust has made changes to its guidelines and has taken action to ensure there are clearer systems in place to prevent the mismanagement of breech deliveries. Following today’s conclusion we are encouraged to hear that the issues will be raised with the Chief Medical Officer in the hope that this will influence national change.

“Bonnie and I share our birthday and we just don’t know how we will feel every time that date comes around.”

If you or a loved one has suffered as a result of negligent delivery, we may be able to help you claim compensation. See our Medical Negligence Guide for more information.