Delays in delivery room led to death of baby

Rotherham coroner Nicola Mundy
Rotherham coroner Nicola Mundy
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A DEVASTATED mother whose baby died because of a delay in delivery at a Yorkshire maternity unit has has called for the NHS to review its practices as a result of the tragedy.

Ava Parkes died at just seven hours old after one of her shoulders became trapped against her mother Katie Pilling’s pelvis during birth, an inquest heard.

Rotherham coroner Nicola Mundy found that the delay between the delivery of the baby’s head and body placed her under “increasing stress” leading to her brain being starved of oxygen.

The inquest heard that Ava’s head was delivered safely but her body was stuck due to a condition called shoulder dystocia so she could not start breathing properly on her own.

Guidelines give medical staff five minutes to extract the baby using recognised internal manoeuvres.

In 96 per cent of cases the child is delivered in three to four minutes but in Ava’s case seven manoeuvres were tried and it apparently took far longer.

The coroner returned a narrative verdict, but decided that on the balance of probabilities it took 12 minutes for the baby to be fully delivered whereas medical notes at Rotherham Hospital recorded five minutes.

After the inquest hairdresser Katie, 25, of Byron Road, Mexborough, South Yorkshire said: “We believe a doctor should have been called much more quickly once it was obvious that Ava was stuck.

“Both the junior and senior midwife that were looking after me were unable to free Ava’s shoulder when the emergncy happened.

A registrar who had been called for but was busy in theatre eventually attended and delivered Ava but we believe it was too late by then to save her.

“We hope the hospital acts on the coroner’s verdict and improves its internal systems to ensure this doesn’t happen again.”

The inquest heard Katie’s labour went slowly on October 23 last year and a decision was taken to induce the baby’s birth but she was still not delivered an hour later.

Ava’s grandmother Sandra Pilling became anxious and started “clock-watching” and said the baby’s head was visible at 12.23pm but there was a delay before medical staff raised the alarm.

She said the baby was fully born at 12.42pm and added: “All I could think about was ‘will she be able to breathe?’

Dr Eleni Lekoudis said she was buzzed to the labour ward and found the baby’s head was delivered but midwives were having difficulty getting the body out.

She told the Rotherham hearing: “The baby was very, very stuck and not moving at all. I thought I might not be able to deliver her.”

The coroner said the events were a “very fraught and distressing situation for all involved” and the timings surrounding Ava’s birth were “far from clear.”

But entries in the medical notes were done retrospectively by staff and Ms Mundy added: “I do not for one minute suggest there was any deliberate attempt to mislead.

“But I question the independence, reliability and cogency of the various entries throughout.”

Family solicitor Laura Craig said afterwards: “When complications arise during childbirth every second counts. Sadly a significant time passed between when Ava’s head was delivered and when she was fully born.

“We believe Ava would have had a fighting chance if an obstetric registrar or consultant had been contacted sooner to help with the delivery.”

Katie and her partner Nicky Parkes have made a formal complaint and their lawyers will now consider whether to claim compensation.

A spokesman for Rotherham NHS Foundation Trust said: “We always aim to deliver the best levels of care and we did undertake a full and thorough investigation into the treatment Ava received.”