Coroner blames maternity unit delay for death

The coroner ruled the delay had been largely to blame for the tragedy and criticised management standards at Dewsbury and District Hospital, also suggesting the baby boy’s parents could sue.

Sarah Dawson, 33, should have been given the choice of an assisted birth as soon as her waters broke, the hearing was told, but a caesarean was not carried out for 61 hours due to a shortage of beds and midwives.

By the time it was carried out Sarah and partner Phillip Schofield’s child Oliver Charles Schofield had succumbed to an infection and was certified dead from pneumonia after 42 minutes.

Recording a narrative verdict yesterday, West Yorkshire Coroner Professor Paul Marks ruled that “the delay in inducing labour and proceeding to delivery was a material contribution to the death”.

He praised the couple’s dignity during the proceedings at Bradford Coroner’s Court and said Oliver’s death must have been particularly tragic to bear.

He added: “You may be interested to know that any person who believes they have some course of action may still bring an action in the courts.”

Following the tragedy in July 2010 Mid Yorkshire NHS Trust had supposedly amended its policy guidelines so they were in line with the national NICE guidelines on patient care but yesterday’s hearing was told the trust still refused to induce births straightaway if a woman’s waters broke in the evening, as Miss Dawson’s had done.

Just like Miss Dawson, they were told to come in the first morning after the 24 hours had elapsed, meaning there was still a “built in delay” which increased risks, the coroner said. He will be taking the matter up with trust bosses.

Earlier, Prof James Walker, Senior Vice President of the Royal College of Obstetricians, giving evidence as an expert witness, also questioned the review.

“I do not understand how they can incorporate the NICE guidelines in their guidelines – and then not follow the NICE guidelines,” he said, describing what had happened as a “concatenation of errors”.

Miss Dawson and Mr Schofield, an electrician, of Morley, Leeds, accused the trust of negligence.

The two-day hearing was told the teacher’s waters broke about 7pm on July 12 but trust policy was not induce births in the evening in case things went wrong during the night. It also favoured a 24-hour wait to see if labour started naturally, meaning Miss Dawson was not called in to be induced until July 14.

She was then kept waiting most of the day because the bed she was told would be available was not free because the unit was so busy and one midwife short. In the end she stayed in overnight, unable to sleep as she was sobbing in pain due to contractions, until labour began early on July 15.

Prof Walker said Miss Dawson should have been offered the choice of having the baby induced on the evening of the 14th.

“It should be up to the woman to decide whether she has an induction or delays 24 hours,” he added. “If she chooses to wait 24 hours she should be told there’s an increased risk of infection.”

The hearing heard how the delay may also have been increased by registrar Dr Davison Nyambo embarking on a different course of treatment to that recommended in the original management plan.

Simon Crimland, the barrister representing the family, said the doctor’s suggestion of another review in 24 hours would have meant even more delay.

After the hearing, Miss Dawson, now 34, said: “Phillip and I have been completely devastated by the loss of our son, and it is horrible to know that his death was due to a simple lack of care being available to us when we needed it.”

“We hope the Trust will acknowledge that they made mistakes in our case and can apologise for the loss they have caused us. I find it hard to get through each day knowing that Oliver should still be with us. Changes need to be made to prevent this from happening in the future.

“No one else should have to go through what Phillip and I have.”