Professional body responds to coroner's report into mistakes that cost a baby's life

Baby Ted Stewart began to be born feet first, an hour after his mother Stacey got home after being discharged from Sheffield’s Royal Hallamshire Hospital.

Ted was delivered unresponsive in an ambulance on the way to hospital. He died eight days later from a brain injury caused by head entrapment during the breech delivery. Mrs Stewart had attended hospital with pain and bleeding at 38 weeks’ pregnant on December 11 2024.

She was examined by a junior obstetric doctor, who identified that Ted may be in an “oblique lie” where the baby is positioned diagonally across the mother’s womb, rather than lying vertical or horizontal. An inquest earlier this year heard the doctor was “unaware of the significance” of such a presentation, what next steps to take, and guidance was lacking.

His parents were reassured there was no active bleeding and they could go home ahead of a planned C-section. However shortly after returning home, Mrs Stewart went into active labour.

Coroner Hannah Berry found she should have been admitted to hospital and if she had “on the balance of probabilities Ted would not have died”.

She wrote a “prevention of future deaths” letter to the RCOG and National Institute for Health and Care Excellence to highlight the lack of guidance on babies in “oblique” position . RCOG said Baby Stewart’s death was a “devastating tragedy” for his parents, family and healthcare staff . It said women with a “non-longitudinal lie at term should have individualised counselling as to their options for care from an experienced obstetrician”.

The College said maternity triage –a 24/7 dedicated assessment service - “must be formally designated as a safety-critical clinical environment, with binding national standards” and adeq uate staffing to ensure “timely access to senior clinical decision makers” .