NUH accepts baby boy would have survived if delivered earlier at QMC

A general view of The Council House in Old Market Square, Nottingham city centre.
-Credit: (Image: Joseph Raynor/ Nottingham Post)


Nottingham University Hospitals (NUH) NHS Trust has accepted a baby would have survived had he been delivered sooner, an inquest was told. Emir Ayhan 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.

A three-day inquest commenced at Nottingham Council House on Wednesday, May 29, while an investigation conducted by the Maternity and Newborn Safety Investigations was also conducted. Coroner Elizabeth Didcock said baby Emir's cause of death was 1(a) hypoxic ischaemic encephalopathy, followed by 1(b) placental abruption.

Coroner Didcock said: "In this case the Trust accepts that there was an opportunity for the baby to be delivered earlier than he was and if he had been delivered earlier, on balance, he would have survived." The baby was born at 38+ weeks and the mother presented in labour and with vaginal bleeding.

READ MORE: Inquests open into deaths of babies born within a week of each other at QMC

She had an emergency C-section as the baby was distressed. At the time of the C-section she was found to have a placental abruption (a separation of the placenta from the uterus) and Emir was born in a "very poor condition" and needed extensive resuscitation.

Coroner Didcock said it was "clear" that he had sustained a severe brain injury and sadly, despite receiving extensive care support, he did not recover. Baby Emir died at NICU on August 5, 2023, and the cause of his death was established at the post-mortem examination undertaken at the instruction of the coroner.

This was undertaken by Doctor Simi George, pathologist, at St Thomas' Hospital in London. During the examination, the baby appeared normal, not suggesting any abnormalities or malformations.

The internal examination and the examination of the tissues under the microscope confirmed the injury to the brain caused by the lack of oxygen. The pathologist explained that there was an abruption of the placenta and that this could not be seen at the post-mortem examination but was the likely cause of death.

There was nothing significant in the examination of the placenta but because of the history of the vaginal bleeding seen at the time of delivery, she believes this was the cause of the brain injury and multi-organ failure. The inquest then heard evidence from Doctor Gemma Wright, consultant obstetrician and clinical quality director at the Trust.

Dr Wright, although not directly involved in the care of Emir, reviewed the care provided to the baby. She told the court how on July 18 at around 1am, Emir's father called the advice line as the mother was having contractions.

The mother was unable to report on the foetal movements due to the pain and it was documented that she did not have any bleeding at the time and the couple were asked to attend the labour suite. They arrived on the labour suite at 2.22am.

This was a day during the junior doctors' industrial action in the summer of 2023 and, as a result, the doctors on the labour suite were the same number as normal but they were consultants or of consultant level. There were two consultant obstetricians and a senior doctor equivalent to a consultant working that night.

Dr Wright told the inquest that midwifery staffing was reasonable for the activity of that night. At 2.45am, Emir's mother was triaged by a midwife.

There was a short delay in the midwife's attendance as she was providing care for another woman. This meant that the initial triage took place 23 minutes after admission, rather than within the 15-minutes target. The woman was given a score of two, which suggested some concern.

The mother was in a moderate amount of pain associated with labour but it was noticed she had vaginal bleeding. The midwife says the mother's womb remained soft during the contractions. The mother provided a routine urine sample which showed the presence of blood and protein and also had high blood pressure.

After this, she should have been rated a six, suggesting increased level of concern, but remained a two. Dr Wright explained that two points came from the vaginal bleeding, two from the protein present in the urine sample, and two for the increased blood pressure.

The incorrect rating was not due to an error on the midwife's behalf, but because of how the computer system works, the inquest heard, with Dr Wright adding that a new system is expected to become available towards the end of this year. Guidance is available as to what staff should do in this instance, which suggest an obstetrician should be involved, rather than a midwife.

The midwife said in a statement she then made an escalation at the labour desk to an obstetrician and a doctor simultaneously. According to evidence given by Dr Wright in Wednesday's hearing, the obstetrician says she was informed of the escalation first, and she then subsequently informed the doctor, who was in an operating theatre but not scrubbed in.

The inquest continues and is expected to conclude on Friday, May 31.

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