A coroner has ruled a newborn baby might have survived if it hadn’t been for ‘negligence’ on the part of Royal Stoke University Hospital. Addison Lea Stevenson was born at 30 weeks and five days gestation on September 21 following an emergency C-section.
An inquest heard yesterday that her mother Donna Lea had been admitted to Royal Stoke three days earlier with ruptured membranes. The mum-of-four was placed in the delivery room due to the high likelihood of a premature birth within 48 hours.
However, on the morning of September 20, her care was defused and she was transferred to the antenatal ward. The inquest heard that Donna should have remained in the delivery room.
READ MORE: Devastated mourners say goodbye to ‘little princess’ Addison
Then things took a tragic turn for the worse later that day. Donna’s repeated concerns about noticing a reduction in the baby’s movements were not addressed by midwives until about two hours after she said she had reported it to a support worker at the maternity at 4 p.m.
In a statement to the inquest, the maternity support worker said she was ‘angry and upset’ that her concerns were not addressed by the two midwives. She said: “I emailed my duty manager expressing concerns about an incident during this shift involving Donna.
“I was angry and upset that the concerns were not addressed by both midwives. I informed them numerous times of the concerns raised by Donna.”
The maternity support worker then added that one of the midwives responded to her concerns at the time: “She’s pretending…she just had a cigarette, she can’t be in so much pain. .”
However, this contradicted statements provided by the two midwives who said the maternity support worker did not inform them of the reduced fetal movement until 6:20 p.m. How well they acted on concerns.
An ECG was performed which revealed baby Addison was tachycardic. Mum Donna was moved to the delivery room for an emergency C-section, but sadly Addison passed away hours later, leaving her parents, Donna and Nathan Stevenson, heartbroken.
Addison died of complications from chorioamnionitis. A catalog of failures led to delaying this diagnosis.
The catalog of failures included:
- Donna was not seen in person by a consulting obstetrician until her care was deescalated and she was transferred to the antenatal ward on September 20. The inquest heard she should have remained in the delivery room;
- When Donna was transferred from the delivery room to the antenatal ward, her antibiotics to treat a urinary tract infection (UTI) and intrauterine infection were reduced from intravenous to oral antibiotics after her results were “poorly interpreted”;
- There was a missed opportunity to perform electronic fetal monitoring on September 20 in the antenatal ward. This would have led to a decision to deliver Addison earlier;
- There was a delay in the diagnosis that Addison had chorioamnionitis.
Donna Brayford, head of quality and risk at Royal Stoke’s Maternity Centre, carried out a root cause analysis after Addison’s death. The trust is currently implementing an action plan with “systemic” changes.
This includes requiring a consultant obstetrician to be present for morning and evening rounds and a rapid escalation process for staff to escalate concerns if they feel they have not been addressed.
Ms Brayford said: “The first root cause was the lack of face-to-face consultant attendance during the round of services. We have now made it mandatory for an obstetrician consultant to be present in the morning and evening, in line with national regulations guidelines.
“The second is that all mothers whose care needs to be defused should be seen by a consultant obstetrician. They will remain in the delivery room until they are seen by a consultant obstetrician.”
Ms Brayford added: “We are also introducing a rapid escalation process. When the support worker raised her concerns with the midwives, she felt her concerns had not been addressed.
“She could now move on to the next responsible person to escalate her concerns. There are now signs all over the ward showing who you can go to if you disagree with a decision.”
A contributing factor to Addison’s death was also understaffed in the prenatal ward. Ms Brayford told the inquest that 26 Band 5 midwives and five international midwives have since been recruited by the trust and a further 20 are expected to be recruited by the end of the year.
Due to the inconsistencies between the midwives and the maternity support worker, a referral was also made to the head nurse to decide if further investigation by management is required.
A cause of death was provided as 1A E. coli sepsis, 1B chorioamnionitis and in part 2 prolonged premature rupture of membranes.
North Staffordshire Deputy Coroner Sarah Murphy found Addison’s death was ‘contributed to negligence’.
She said: “There was a gross failure to provide basic medical care. I find negligence. The death was caused by negligence.” She added: ‘It is very clear that the hospital trust looked very carefully at system errors and individual errors.
Addressing Addison’s devastated parents, Miss Murphy added: “I hope you could see that the hospital has taken this death very seriously. No one can bring your baby back, but I hope if the same circumstances happen again, so measures are in place now to try to prevent a similar death. I hope this can be a source of comfort for you.
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