'Missed opportunities' in care of baby boy who died at Nottingham's Queen's Medical Centre

The Queen's Medical Centre in Nottingham
-Credit: (Image: Nottingham Post/ Ian Hodgkinson)

A coroner concluded that the death of a baby could have been avoided if he had been delivered just 13 minutes earlier. A three-day inquest into the death of Emir Ayhan began on Wednesday, May 29, at Nottingham Coroner’s Court and was led by Coroner Didcock.

During her conclusion, on Friday, May 32, she ruled that the cause of death was 1a hypoxic ischaemic encephalopathy, followed by 1b placental abruption.

Emir was born at the Queen’s Medical Centre on July 18, 2023, but died 18 days later at the hospital due to a lack of oxygen to the brain after birth. During her conclusion, Coroner Didcock explained that Nottingham University Hospitals Trust (NUH) had failed to follow certain guidelines relating to the urgency of labour and constant monitoring of Emir through an ECG.

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Whilst an ECG monitored a normal foetus heartbeat initially, contact was lost and could not be re-established after his mum had been sick and experienced further bleeding. This is one of the points where the matter should have been escalated, as it is suspected that during the time of no ECG the baby’s heartbeat de-escalated due to a lack of blood and oxygen supply, the inquest was told.

The inquest was told that, on the balance of probabilities, if Emir had been delivered 13 minutes earlier then he would have survived. However, this does not mean he would have been born without any brain damage caused by the placental abruption (a separation of the placenta from the uterus), the hearing was told.

Emir was delivered after 38 weeks and his mother presented in labour and with vaginal bleeding. This bleeding is understood not to have been continuous, but occurred a few times and should have signified to staff an urgency or possible problem.

Her baby became distressed and she underwent an emergency C-section, during which she was found to have a placental abruption.

This led to Emir being born in a "very poor condition" and he did not have a heartbeat, show any breathing efforts or movement. Coroner Didcock said: “The trust has acknowledged that, on the balance of probability, if Emir had been born 13 minutes earlier he would have been born in a better condition and would not have needed as much resuscitation.”

Extensive resuscitation was given but sadly despite the hospitals best efforts, Emir died on August 5, 2023 at 19 days old. Coroner Didcock added: "I wish to extend my sincere condolences to the parents and all the family and friends, I’m so sorry for their loss.”

Shrdha Kapoor, specialist inquest solicitor and associate at law firm Nelsons, has been assisting the parents during the process, said: “The inquest has highlighted many concerns regarding midwifery and obstetric care provided at Queen’s Medical Centre. In her conclusion, the Coroner stated there was an underestimation of the risk to baby Emir from the mother’s arrival on the unit onwards, and there were clear warning signs of an evolving placental abruption that were not heeded; these signs included vaginal bleeding and concerning features on the CTG of Emir’s heart rate.

“Sadly, the missed opportunities to escalate concerns within a timely manner led to an avoidable delay in delivering baby Emir and if he had been delivered 13 minutes sooner, it was established that he would have been born in better condition and would have survived.

“It was also identified that the Trust is not currently meeting the needs of its diverse population. The lack of interpreting services available prior to and during Emir’s birth only added to the trauma and distress of his parents’ experience.

“While the Trust was able to provide evidence on the various improvements made and to be made across its maternity services, this has provided little reassurance to Emir’s parents that real and impactful change will happen, to prevent other parents from suffering such a devastating loss - particularly as the Trust failed to comply with its own clinical guidelines on managing women with antepartum haemorrhage. This is also in the context of previously reported inquests relating to similar circumstances and the ongoing maternity review being conducted by Donna Ockenden.

“The Coroner welcomed the various proposed actions by the Trust to prevent this happening to another family, and requested for the Trust’s review on antepartum haemorrhages to be shared with her on completion, which is expected to be in December 2024.

“Sadly, for Emir’s parents, nothing will bring back their much loved son and it is very difficult for them to be told by the Trust just over one week prior to the inquest, that Emir’s tragic death in August 2023 was avoidable if it were not for shortcomings in the care provided. The parents’ trust in the NHS system as a whole has been completely shattered.”

Tracy Pilcher, Chief Nurse at Nottingham University Hospitals NHS Trust (NUH), said: “We would like to offer our sincere condolences to the family of Emir for their loss.

“We accept that there were failings in Emir’s care and are truly sorry that we were not able to offer the appropriate standard of care for Emir and his family.

“We have fully reviewed the case in order to assess and strengthen our approach, and as a result have implemented changes to support maternity staff and patients in the future.”