Parents Instruct Irwin Mitchell To Investigate After Boy Diagnosed With Cerebral Palsy

A baby suffered a serious brain injury after hospital staff failed to ‘recognise and respond’ to abnormalities in his heart rate several times during his mum’s labour, an internal investigation has found.

Iszak Derby has been diagnosed with cerebral palsy and epilepsy as well as hearing and sight problems following his birth in June this year at University Hospital Coventry.

After an 18-hour labour and around five hours after a monitor first indicated suspicions about his heart rate, Iszak was delivered by emergency caesarean. Staff spent 13 minutes trying to resuscitate him. Iszak suffered a serious brain injury caused by a lack of oxygen, an incident investigation report published by University Hospitals Coventry and Warwickshire NHS Trust said.

Iszak spent the first six days of his life on a ventilator, including five days in intensive care.

His parents Kyza and Alice, aged 31 and 26, have now joined their specialist legal team at Irwin Mitchell in using World Cerebral Palsy Day to call on the Hospital Trust to ensure it implements recommendations included in its own action plan designed to reduce the risk of similar incidents.

It comes after an internal Trust report also found the workload labour ward staff faced resulted in them losing awareness of the situation. A lack of communication   prevented them escalating concerns to more senior doctors.

Expert Opinion

“This is an incredibly emotional time for Kyza and Alice as they still struggle to come to terms with the events that happened during Iszak’s birth.

“People with cerebral palsy have complex needs and it is anticipated that Iszak will need a range of specialist rehabilitation and therapies as he grows older.

“Kyza and Alice have instructed us to investigate more could have been done during Alice’s labour to prevent Iszak’s injuries and to help them access the specialist support he will need in future.

“We recognise that the Trust 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.” Jenna Harris - Partner

Kyza, an insurance consultant, and Alice, children’s services team leader, of Longford, Coventry, were expecting their first baby whose due date was 1 July.

However, having experienced two occasions of reduced fetal movement on 23 May and 18 June, following consultation with medical staff, Alice attended University Hospital Coventry on 23 June to be induced.

On 25 and 26 June regular observations and fetal heart rate monitoring were conducted. However, the following evening Alice complained of ‘feeling uncomfortable’, the investigation report said. Monitoring of Iszak’s heart rate started and Alice was transferred to the hospital’s labour ward.
  
At around 12.15am on 27 June Alice’s waters were broken. Alice started being administered syntocinon, a drug designed to speed up labour at 7.15am. At 9.30am a consultant noted the baby’s heart rate from a cardiotocography (CTG) machine to be ‘normal’.
 
Several decelerations in Iszak’s heart rate were recorded in the morning. At around 1.20pm a doctor recorded the CTG results as suspicious and Alice’s syntocinon dose was increased.

Staff sounded the emergency buzzer around 25 minutes later following a ‘prolonged’ low fetal heart rate.

The investigation report said that at around 2.30pm a midwife raised concerns over the CTG results to a doctor writing in medical notes that ‘intervention is required’. However, the report said that the doctor did not remember this and they were elsewhere on the labour ward at that time. 

Further slowing in Iszak’s heart rate and suspicious readings were recorded throughout the afternoon, including just before 5.10pm when the heart rate monitor stated Iszak’s condition was ‘pathological’.

At around 5.45pm a midwife interrupted a medical staff handover meeting to ask for a review. A further request for an urgent review was made nine minutes later.

Iszak was delivered by emergency caesarean at around 6.20pm.

The Hospital Trust conducted an investigation which concluded there was “a failure to recognise and respond to abnormalities” in the recording of the baby’s suspicious heart rate until it was recognised it was pathological.

The report also found the work load of labour ward staff resulted in a “loss of situational awareness failure to ask for consultant review” and “failure of team working and communication appears to have prevented the escalation of concerns.”
 
The Trust said it had introduced a number of measures since Iszak’s birth to improve care including any staff that had not completed updated training on using CTG heart scan machines were taken off clinical duties until they had completed it.

A working party has been set up to undertake a ‘comprehensive overview’ of CTG monitoring.
 
Maternity staff and on call doctors are due to start holding twice daily meetings to improve communication and knowledge of workloads. Staff will also be told how and when to escalate concerns.

Alice said: “We still cannot really believe what has happened to our family. It is so difficult to try and describe the last few months. 

“We are not sure what the future holds as we are still waiting to hear about the extent of Iszak’s injuries and how they will affect him.

“What is certain though is that we will give him all the love and care we can. Iszak means everything to us.”

Kyza added: “It is hard not to feel angry about what has happened to our family. We now want answers to the many questions we have about the care Alice and Iszak received and if more should have been done to prevent my boy’s injuries. 

“We just want to find out more so hopefully others families don’t have to go through what we have.”

World Cerebral Palsy (CP) Day is Saturday, 6 October. The aim of the awareness raising day is to ensure that children and adults with cerebral palsy (CP) have the same rights, access and opportunities as anyone else in our society.

There are an estimated 30,000 children with cerebral palsy in the UK. It is usually caused by injuries during birth and leaves those affected with varying conditions that affect muscle control and movement. They may also have learning difficulties, epilepsy and communication difficulties.

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