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Health Board Criticised Over Hospital Death of Newborn Infant Died After Receiving 'Inadequate Care'

Posted on: Tuesday, 15 November 2005, 06:00 CST

By TOM GORDON

A HEALTH board has been ordered to apologise to the mother of a newborn baby who died after receiving inadequate care at the hands of doctors and midwives.

Professor Alice Brown, the Scottish public services ombudsman, also said NHS Lothian must review its procedures and pay the woman GBP500 for the distress she suffered during an unnecessarily long investigation into the case.

The woman, identified only as Mrs C in the ombudsman's report issued yesterday, lost her son Louis five days after he was delivered by emergency Caesarean section at St John's Hospital in Livingston, West Lothian. The cause of death was a lack of oxygen to the brain, caused by inhaling meconium, or fecal matter, in the womb.

An independent report by medical experts found that, if the hospital had induced the birth earlier, the baby could be alive today.

Mrs C's problems began in October 1998 when the hospital estimated that she was 12 weeks' pregnant, based on the date of her last period.

However, an ultrasound put the pregnancy at eight days longer.

Despite the ultrasound being more accurate, the hospital continued to date Mrs C's pregnancy by the date of her last period, meaning the extent of gestation was underestimated.

In May 1999, Mrs C went into spontaneous labour.

Despite Louis's heart being found to be abnormal and meconium detected during labour, "poor communication" delayed a Caesarean section, with Louis suffering a "severe and prolonged asphyxial assault".

The medical experts concluded: "If Mrs C had been induced eight days earlier, we consider it likely that Louis would not have been in the already compromised condition that he was when Mrs C was admitted in labour.

"It is likely therefore that he would have been delivered in better condition than he was and would have stood a much better chance of surviving."

They also found staff had taken an inadequate history from Mrs C, failed to record antenatal care properly, and delayed assessing her condition while in labour.

Compounding the medical failings, the West Lothian Healthcare NHS Trust took three and a half years to investigate the case - a clear breach ofhealth service complaints rules. Mrs C said she was "raging" at her treatment, feeling she had to "battle" them to see the files on her case.

In her report, Professor Brown upheld three of four complaints against the West Lothian trust, and told its successor, NHS Lothian, to review its maternity records to see if appropriate menstrual histories were taken. Midwifery care should also be reviewed, Professor Brown said.

She ordered the board to pay Mrs C GBP500 "in recognition of the time, trouble and distress caused by the trust's unacceptable handling of her complaint".

She said: "This is a very sad case and it has clearly been very distressing for Mrs C. She has told my office a key motivation for doing so has been to bring about improvements in the health service, and particularly in maternity care. I hope she will feel that the recommendations made in this report will serve to meet that aim."

Stewart Maxwell, the SNP's deputy health spokesman, said:

"This is truly a saddening case.

It is important that lessons are learned in order to ensure it never happens again."

Dr Charles Swainson, medical director of NHS Lothian, said he would study the ombudsman's report closely and had arranged to meet Professor Brown to ensure that lessons were learned.

Source: Herald, The; Glasgow (UK)

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