Coroner Raises Concerns That Hospital Is Yet To Change Procedures – 11 Months After Baby’s Death

Medical law specialists at Irwin Mitchell are urging a West Yorkshire hospital to learn from its mistakes and improve its procedures after a newborn baby died when staff shortages and lack of equipment led to a 61 hour delay in his delivery.

A Coroner today (15 June) raised concerns that 11 months after the baby’s death Dewsbury and District Hospital still hadn’t made changes to its procedures – meaning that the same mistakes could still happen again. The hospital’s own internal investigations also revealed staff failed to keep to the correct care plan and didn’t keep appropriate records during the birth.

Sarah Dawson, 34, from Morley, Leeds, and her partner, Philip Schofield, 33, were thrilled at the prospect of starting a family when she fell pregnant with her first baby in late 2009.  The pregnancy was uneventful until her waters broke on the evening of 12 July 2010, when she was 37 weeks pregnant.

Despite attending Dewsbury and District Hospital the same evening it was not until 61 hours later that their baby, Oliver, was delivered by caesarean section. By this time the baby was in a poor condition and he was born unresponsive. Attempts to resuscitate him failed and he sadly died on 15 July.

Today Bradford Coroner Professor Paul Marks criticised the care Ms Dawson received at the hospital throughout the birth and recorded a narrative verdict. He also found that the delay in inducing labour “materially contributed to Oliver’s death”.

Professor Marks now plans to write to the Trust’s Chief Executive to raise his concerns that, even though the hospital conducted its own investigation into the case, nothing had been done to change procedures.

He added that the current practice at Dewsbury and District Hospital, which does not allow patients to be induced in the evening, causes “a built in delay” as patients are forced to wait till the following morning.

Dewsbury and District Hospital has since conducted its own investigation into the incident, finding that there was a failure to follow a care plan, there was a lack of equipment for fetal blood sampling and there were omissions in the record keeping by staff. 

Law firm Irwin Mitchell, which is representing Oliver’s parents, is urging the NHS to act on the findings from the inquest and investigation to ensure important lessons are learned from the errors in this case. 

Suzanne Munroe, a Partner in the Medical Law team at Irwin Mitchell, said: “This is an extremely sad case which could and should have been prevented. The delays in delivering Oliver are inexcusable and we are extremely concerned that the hospital has still not changed its procedures despite the fact that there is clearly an issue.

“As it stands, if another expectant mother was to attend Dewsbury and District Hospital in the evening they would still be sent away, and this could lead to exactly the same scenario developing again.

“Urgent action must be taken to change the policy so that patients are able to be induced in the evening or at the latest the following morning. Nothing can ever be done to turn back the clock, but Oliver’s family want to know changes are being made to prevent this kind of tragedy in the future.

“Irwin Mitchell has repeatedly called for improvements in safety standards and will continue to campaign for the victims we represent until simple mistakes like these are eradicated.”

Oliver’s mother, Sarah Dawson, said: “Philip and I have been completely devastated by the loss of our son, and it is horrible to know that his death was due to a simple lack of care being available to us when we needed it.

“We hope the Trust will acknowledge that they made mistakes in our case and can apologise for the loss they have caused us. I find it hard to get through each day knowing that Oliver should still be with us.

“Changes need to be made to prevent this from happening in the future. No one else should have to go through what Philip and I have.”