Millie-Rae Needham died in August 2020 after staff in the Jessop’s Wing of Sheffield Teaching Hospitals failed to monitor her heart rate, leading to her being born in a “very poor condition”.
An inquest into the baby’s death found that staff had classed her mother’s pregnancy as high-risk, and when she went into labour, a midwife assessed that she would need an episiotomy – a cut which allows a child to be delivered quickly.
But a second midwife, called in to help with the episiotomy instead encouraged Millie-Rae’s mother to continue with her labour, resulting in a 23-minute delay to her birth.
The baby was starved of oxygen, leading to her death three days later.
Assistant coroner Abigail Coombes said she was concerned that the first midwife was able to be talked out of giving the episiotomy, and expressed worries that women under the care of the Trust are being encouraged before labour to give birth vaginally on the midwife-led ward when a Caesarean section may be a safer or more appropriate option.
A checklist pregnant women are invited to fill in refers to their chances of a “normal birth” being highest on the midwife-led ward as opposed to the consultant-led area.
Coombes said she was concerned that Millie-Rae’s mother had been moved to midwife-led care as opposed to being looked after by a consultant.
In a letter sent to bosses at Sheffield Teaching Hospitals NHS Foundation Trust, she wrote: “A decision was made by the midwife who had been with (Millie Rae’s mother) throughout her delivery to move to an episiotomy. Instead, the midwife that came to support encouraged further position changes leading to delay in delivery and inadequate monitoring of the foetal heart rate.
“Whilst the decision seek support for the episiotomy is not one which I would criticise, people should always be able to ask for help when needed, the fact that the midwife who was with was talked out of this so readily resulting in avoidable delay is concerning.”
The Trust has 56 days to respond to the letter to set out how they will prevent future deaths – the second time in weeks that Abigail Coombes has ordered answers following a baby death on the Jessop’s Wing.
It comes after the Trust was rated inadequate by the Care Quality Commission in a report earlier this year.
Sheffield Teaching Hospitals NHS Foundation Trust was approached for comment.