Baby Matilda Pickup was delivered by emergency Caesarean section following an unsuccessful attempt at a natural birth using forceps at Harrogate District Hospital in the early hours of July 3, 2018, despite mother Whitney Pickup having previously undergone an emergency Caesarean for her first child.
An inquest held at Harrogate Pavilions today (Wednesday) heard that there had been various missed opportunities in Matilda's birth, including that doctors had not had access to Mrs Pickup's previous medical notes from another hospital trust detailing the Caesarean.
Matilda was born with severe brain damage and transferred to Bradford Royal Infirmary, then to Martin House Children's Hospice in Leeds on July 12 where she sadly passed away the same day.
Mrs Pickup, 33, and her husband, Andy, 35, who are from Knaresborough, are currently campaigning for medical records to be shared between hospital trusts so they can prevent further tragedies.
Speaking on the third day of a four-day hearing on Wednesday, consultant obstetrician Dr Kathleen Graham gave her expertise on the actions taken by doctors and midwives in the delivery of baby Matilda, which she called a "deteriorating situation".
Monitoring had shown concerning irregularities in Matilda's heart rate while Mrs Pickup was in labour, while the mother was not given all the information she needed to make an informed decision as to whether she wanted to proceed with the natural birth or opt for a Caesarean, Dr Graham told the court.
When asked by Tom Semple, representing the family, whether an elective Caesarean would have meant Matilda survived, Dr Graham replied: "On balance, yes. I would never say never, but yes."
Evidence also heard PH tests to monitor whether Matilda's oxygen levels were too low were not taken directly before the birth, and that there were various delays in the process of the infant's delivery when time was of the essence.
Dr Graham also told the court: "Each individual hospital trust has its own computer system and they don't speak to each other, so I can't look (at a patient's medical history) with ease. It requires a letter going to that trust, and it can take months - sometimes five or six months - to hear back.
"This is a national problem."
Medical director for Harrogate District Hospital NHS Foundation Trust, Dr Janet Andrews, told the court that a subsequent report had identified a number of problems occurring in Matilda's delivery, and that the Trust was currently in the process of implementing various changes to ensure such a tragedy would not happen again.
Efforts were also being made to improve communications between hospital trusts to allow them to share medical records, Dr Andrews said.
The four-day hearing is expected to conclude tomorrow (Thursday).