Yahoo News Newborn's death 'contributed to by neglect' as coroner says 'he could have survived'
A baby who died from a brain injury at just five-days-old would have survived had he been delivered sooner, a coroner has concluded. Arlo Phoenix Lambert died on March 9, 2023, at Queen's Medical Centre after being transferred from King's Mill Hopsital, where he was born on March 5.
Coroner Laurinda Bower found that Arlo’s death was "contributed to by mismanagement of labour and multiple missed opportunities to have expedited his delivery", following an inquest held in May 2024 at Nottingham Council House. She concluded that neglect contributed to Arlo’s death, which came from "a failure to follow Trust guidance".
Annabel Lambert, Arlo's mother, was induced at 40+2 weeks, and following spontaneous rupture of membranes (SROM), she was left for 17 hours without any attempts made to progress her labour. This gave time for the risk of infection to materialise, the coroner found.
During that time, staff failed to properly review Miss Lambert's care plan and discuss modes of delivery with her, when concerns were raised about the position of the baby and her labour was failing to progress, the inquest heard. Coroner Bower found evidence of "multiple missed opportunities to have expedited Arlo's delivery which would probably have prevented his death".
A Prevention of Future Deaths Report will be issued in the coming days following the coronial investigation. Since Arlo's death, Miss Lambert has suffered from post-traumatic stress disorder (PTSD).
Furthermore, the coroner also made a complaint to the General Medical Council in relation to the actions by Specialist Registrar. In oral evidence, they said that they would "cross [my] fingers behind my back and hope and pray the mother would go into labour" instead of implementing an appropriate care plan.
A post-mortem autopsy found that Arlo's brain showed evidence of hypoxic-ischaemic injury. This is where brain cells die because of a period of time spent without adequate oxygenated blood supply, which can occur as a result of delayed delivery following foetal distress.
The coroner found multiple issues with the pre-natal care of Miss Lambert between her induction of labour at 5.15pm on March 2 and Arlo's birth at 4.26am on March 4. Failings were also found in the mother's antenatal care.
At 38+6 weeks gestation, she attended the hospital for a growth scan. At that point, she was offered induction of labour at 40+2 weeks due to some concerns around growth of the foetus.
This course of action was outside the national definition for slowing foetal growth and an induction of labour was not indicated, but "there is no evidence" that Miss Lambert was made aware of that fact, the coroner concluded.
If Miss Lambert had not been offered induction of labour at 40+2 weeks, she would likely have gone into labour spontaneously, coroner Bower stated, and "her previous labours suggest she would not have faced any challenges delivering Arlo".
From when she arrived under the care of Sherwood Forest Hospitals NHS Trust, which runs King's Mill, numerous delays in commencing the induction led to the tragic outcome. Poor communication and a shortage of staff contributed to delays in developing a plan for delivery.
At 11.33am on March 3, the baby's head was found to be presenting high in the pelvis, but there was a missed opportunity to consider mode of delivery and to have counselled mum on the risks and benefits of continuing with induction of labour, or caesarean delivery, in accordance with national guidance, the coronial investigation revealed.
At this point, CTG monitoring was discontinued which was also against national guidance, so the midwives were unable to continuously monitor for any signs of foetal distress. At 5pm, after being asked to confirm the position of the foetus with an ultrasound scan, it was the Registrar who wrote a delivery plan without consulting Miss Lambert's wishes and without knowledge of her situation.
If the induction of labour policy had been followed when labour was not established two hours after SROM, delivery by either method "would probably have avoided his death", she concluded. At the ward round at 9.43pm, there was a communication failure between the midwife and obstetric team to understand that there had been blood stained liquor, which again led to a missed opportunity to consider the mode of delivery.
It wasn't until 3.58am on March 4 that doctors decided to proceed to a category 1 caesarean section for suspected placental abruption. At just before 4.30am, Baby Arlo was delivered by a difficult caesarean section due to his position, following a delay by the midwives recognising that there were complications and alerting the obstetric team for assistance.
Baby Arlo was in a compound position with both a leg and an arm above his head. It was apparent on delivery that there had been a placental abruption given the volume of blood and clot within the uterus.
Arlo was transferred to the neonatal unit at the Queen's Medical Centre, part of Nottingham University Hospitals (NUH), for specialist care, but he sadly passed away five days later. Had Arlo been delivered sooner, he "would more likely than not have survived", the coroner concluded. The conclusion comes as the chair of an independent review into maternity services at NUH, Donna Ockenden, has announced the review team will take a "deep dive" into antenatal care.
This includes ultrasound scanning, antenatal screening for certain conditions, and antenatal diagnosis. Following the publication of a recent Birth Trauma Report, Ms Ockenden told Nottinghamshire Live that, despite her investigation only looking into maternity services at NUH, the report highlights issues across the country.
She said: "Overall, the country has got a huge amount to do to ensure that all women have access to safe, timely, and inclusive care. And it's now the government's responsibility to ensure that all of these actions are put in place across the country."
Chantae Clark of Tees Law, acting for the family, said: "These tragic events were preventable if Sherwood Forest Hospitals NHS Trust had followed guidance and acted on the warning signs in the hours before Miss Lambert's labour. It is hard to believe that in such an advanced healthcare system, a mother should suffer the treatment that she did and that a baby should die because of neglect.
"The immense toll on Arlo’s family shows the devastating impact of these failings. It is of some comfort to the family that the Coroner has carried out such a robust investigation and has found evidence of neglect and issued a Prevention of Future Deaths Report.
"The family sincerely hopes that the Trust implement urgent changes to prevent another avoidable disaster befalling any other family."
Dr Simon Roe, Acting Medical Director at Sherwood Forest Hospitals, said: “We would like to express our deepest condolences and our unreserved apologies to the family of Arlo Lambert for their loss.
“As a Trust, we are committed to providing outstanding care to all of our patients and we’re sorry that we have not been able to provide that on this occasion.
“It is right that cases like these are properly reviewed to strengthen our commitment to providing the best possible care to local families and we’ve already introduced some changes to our guidelines to ensure we implement immediate learning. We will consider the full findings of the Coroner’s Prevention of Future Deaths Report (PFD) to help improve the care we provide in the future.”
