A newborn baby passed away as a result of the severe negligence of three midwives in providing essential medical care, as determined by a coroner.
Ida Lock was delivered at the Royal Lancaster Infirmary (RLI) on 9 November 2019 but tragically lost her life a week later due to a serious brain injury caused by oxygen deprivation.
Following a five-week inquest at Preston County Hall, coroner James Adeley concluded that the midwives’ failure to promptly deliver the distressed infant and the lead midwife’s incompetence in providing basic neonatal resuscitation were the direct causes of Ida’s death.
He highlighted eight missed opportunities to change the course of Ida’s medical treatment.
During the inquest, it was revealed that Ida was moved to the intensive care unit at Royal Preston Hospital’s neonatal department, where she eventually passed away on 16 November 2019.
An independent report from the Healthcare Safety Investigation Branch (HSIB) in April 2020 identified several shortcomings in Ida’s care that contributed to her unfortunate demise.
The report pointed out the failure to notice a critically slow foetal heart rate during early labor and ineffective resuscitation efforts after Ida’s birth.
Despite this, an internal review conducted by the hospital in January 2020 praised the staff’s teamwork in the delivery suite and found no issues.
Concerned by the conflicting reports, Ida’s parents lodged a complaint with University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT).
In his verdict, Dr. Adeley stated that Ida’s death resulted from oxygen deprivation during delivery due to the gross negligence of the three midwives in providing urgent medical care when the distress was evident.
He pointed out that the lead midwife’s incompetence in basic neonatal resuscitation during the crucial first minutes of Ida’s life further contributed to the brain damage.
The coroner also criticized the hospital’s investigation into Ida’s death, describing it as a failure at every level.
UHMBT had previously faced severe criticism in a 2015 report for issues at another maternity unit, Furness General Hospital, leading to several tragic deaths from 2004 to 2013.