Ambulance Staff Unaware Of Latest Breeched Delivery Guidelines

The parents of a newborn baby who died from a severe brain injury after the ‘incorrect’ ambulance was despatched when his mum started experiencing stomach pains are calling for lessons to be learned following his death.

Jack Robinson-Morris was found to be breeched when his mum Sarah Robinson delivered his legs, body and left arm spontaneously in the back of an ambulance on the way to hospital.

Paramedics pulled over and unsuccessfully tried to deliver his head before restarting their journey to hospital. 

A subsequent internal investigation by West Midlands Ambulance Service concluded an ambulance was nearer to the family’s home in Solihull than the one despatched, however, staff were about to finish their shift. Ambulance staff who tried to deliver Jack used the wrong technique. They had not seen the latest guidelines on how to deal with such an incident and the last mandatory maternal emergencies training was five years ago.

Sarah, 30, and the baby’s father James Morris, 37, have now joined their legal team at Irwin Mitchell in speaking out during Baby Loss Awareness Week. They are calling on the Ambulance Trust to ensure it implements recommendations included in its own serious incident report designed to reduce the risk of similar incidents happening.

Expert Opinion

“This is a truly heart-breaking case with Jack’s death understandably having a huge impact on the family. Many months after Jack’s death Sarah and James are still struggling to come to terms with the events that unfolded.

“The findings included in the Ambulance Trust’s own report and the findings of an inquest into Jack’s death are worrying.

“We recognise that the Ambulance Service has made several recommendations in its incident report and we urge it to ensure these are implemented as soon as possible to improve patient care for others.” Zoe Smith - Solicitor

Find out more about Irwin Mitchell's expertise in handling birth injury cases

Sarah was 33 weeks pregnant when she started to develop serious pains and suffered blood loss on 15 April this year. James called an ambulance at 6.14am which arrived 27 minutes later.

Sarah left her home at 7am. At 07.08am Jack’s legs, body and left arm were delivered spontaneously. The ambulance was stopped and attempts were made to deliver Jack’s head using the McRoberts position.

The ambulance arrived at Heartlands Hospital at 7.19am and Jack was delivered using a specialist manoeuvre at 7.25am.

He was taken to the neonatal unit where he was found to have suffered a severe brain injury caused by a lack of oxygen when he his head was trapped during delivery.

He died in Sarah’s arms on 18 April after she and James made the heartbreaking decision to withdraw Jack’s life support following the advice of doctors.

West Midlands Ambulance Service’s report found there was around a 12-14 minute delay in not despatching a closer ambulance to the family home. 

It added staff should not have tried to support Jack when attempting to deliver it but let gravity deliver him.

The controller felt that to task the nearest available ambulance could potentially delay the off going crew and it would have been better to have a fresh oncoming crew to attend to the case, which led to an initial response delay, the report found.

It added that the crew who transported Sarah and Jack to hospital felt they were doing the right thing as there has not been any maternal emergency training for five years and no immediate access to expert obstetric advice or guidance.

The Ambulance Service report made seven recommendations including all staff undergo training, guidance cards of what to do in an obstetric care are introduced and all control staff to be reminded of the Service’s end of shift policy.

An inquest held in August identified a range of concerns regarding the care related to Jack’s delivery, including that the incorrect ambulance was assigned to the case and that this delayed the arrival at hospital and ultimately led to his brain damage.

Sarah said: “It remains incredibly hard to think about what happened to Jack and it is still hard to believe that he is gone.

“Every day is a real struggle. Our arms ache to hold our little boy again. Jack was the most perfect and beautiful little boy who we miss so much.

“It is so difficult not to be angry about what happened, how we feel let down and most importantly how we feel Jack was let down.

“I should be holding my boy in my arms, instead Jack passed away peacefully on my chest.I wouldn’t wish the pain our family is going through on anyone.

“All we can hope for now is that he didn’t die in vain and the ambulance services learns from what happened to him so others don’t have to live with the pain our family is having to endure.”

Baby Loss Awareness Week aims to raise awareness of the issues affecting those who have experienced pregnancy loss or baby death in the UK. It also campaigns for improvements in healthcare, research and bereavement support.