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Inquest Hears Failure To Correctly Interpret Heart Trace Led To Tragic Death Of Couple’s Only Child

Hospital Trust Admits Responsibility After Baby Boy’s Death


An inquest has heard how a series of critical errors made by hospital maternity staff led to the tragic death of a Coventry couple’s only child after they failed to monitor and recognise an abnormal heart trace. 

By the time Lucas Josef Fermor was finally born at Warwick Hospital on 29th May this year, he had been starved of oxygen for so long that he was delivered ‘white and floppy.’  As a result he suffered irreversible brain damage and intensive care specialists at Leicester’s Royal Infirmary’s where he was transferred fought to save his life.

His devastated parents, Natasha and Kent Fermor, were told that nothing more could be done to save their only child and following a christening held in the hospital, he was taken off life support and died in their arms at 9.30pm on May 31st 2012.

Then, two days after Lucas’ funeral, Natasha, 40, was given the devastating diagnosis that she has advanced breast cancer and is now currently undergoing chemotherapy treatment.

Following the inquest, which recorded a Narrative verdict, medical law specialist, Guy Forster from law firm Irwin Mitchell who is representing the couple, urged the hospital trust to confirm that the changes they claim to have implemented since Lucas’ death will safeguard the lives of babies born there in the future.

During the hearing, HM Deputy Coroner for Coventry and Warwickshire, Louise Hunt, heard from the Trust’s own experts who conducted an internal investigation into events in the lead up to Lucas’ death and found that:

• CTG traces monitoring the baby’s heart rate were not correctly interpreted and a trace, showing Lucas was in distress, was missed
• Fetal blood samples which could also have identified Lucas was in distress were not taken

Giving her verdict, she said: “Lucas died from hypoxic ischaemic encephalopathy caused by asphyxia during labour which went undiagnosed and untreated before birth as a result of a failure to correctly interpret the CTG and undertake a fetal blood sample in accordance with the NICE guidelines.

Guy Forster, from Irwin Mitchell, said: “The couple have understandably found the death of Lucas incredibly hard to bear, particularly as he was their first and only child.

“The series of failings which the Trust itself identified are hugely concerning and although, to its credit, retraining of doctors and changes in procedures have since been implemented, the family still has concerns that this could happen again.  We urge the Trust to share the lessons it has learned with other hospitals throughout the NHS to help prevent the same tragedy happening to any other parents.

“Whilst nothing can turn back the clock for Natasha and Kent they the fact that the Trust has now admitted liability is of some comfort.”

Natasha Fermor, a Technical Liaison Director with a marketing agency, said: “The hospital had already identified that because of my age, my pregnancy was ‘high risk’ and as such I should have been carefully monitored during every stage of my labour.

“I was in so much pain because of the drugs they were using to induce the birth, but I was told that everything was fine and as a first time mother I put my trust and the life of my unborn son in the doctors’ hands. Even when they realised that Lucas was in fact in distress, there seemed to be endless delays taking me into theatre for surgery where he was finally delivered.

“Kent kept dashing back and forth between me and the doctors who were desperately working on Lucas trying to get lines into him and resuscitate him.

“When he was transferred to Leicester to undergo cooling therapy in an attempt to limit the brain injury he had suffered, I was still recovering from surgery and wasn’t able to travel with him. I had only seen Lucas for ten minutes after he had been born and at that point I wasn’t aware just how poorly he was.

“When Kent and I saw him in the neonatal intensive care unit, we realised the enormity of the situation. The doctors admitted he was so poorly that the only thing keeping him alive was the life support equipment.

“We knew we had to say goodbye to him and we quickly arranged a Christening service at the hospital and invited close members of our family who came to support us.

“Taking the final decision to turn off his life support is the most difficult thing I have ever had to do but we knew we didn’t have any option and Lucas passed away peacefully in our arms.”

Natasha added: “The battle to cope with Lucas’ tragic and untimely death has been made even worse by the news that I have advanced breast cancer.

“I have already undergone one course of chemotherapy and I am due to start further treatment in the New Year. Despite this, both Kent and I are determined to remain focused on our battle for justice to ensure the hospital has indeed learnt lessons from what happened to Lucas so that no other couple has to suffer the heartache we have endured.”