Baby’s death ‘accident waiting to happen’
A BABY girl who died at just 12 days old would still be alive today if not for the ‘catastrophic state of affairs’ at a hospital maternity ward, a coroner has said.
Scarlett Marshall passed away at St Mary’s Hospital in Manchester in September 2016. Her brain had been starved of oxygen after her mother Tina Saunders faced ‘significant’ and ‘unacceptable’ delays to be transferred for delivery, an inquest into her death heard.
A senior coroner has now said that if Scarlett had been delivered earlier, she would still be alive today.
Following the three-day inquest at Manchester Town Hall, Fiona Borrill criticised management at Manchester University NHS Foundation Trust for failing to take action, after issues were highlighted in a report more than a year before the infant’s death.
Scarlett’s death was ‘an accident waiting to happen,’ according to Ms Borrill.
Miss Saunders and partner Christopher Marshall previously told of the heartbreaking moment they decided to withdraw their daughter’s life-support.
Scarlett failed to regain brain activity after she was born on September 18, five days after her mother’s admission to hospital. Miss Saunders was 37 weeks pregnant when she was taken into St Mary’s Hospital to be induced on September 12, 2016, the inquest heard.
She believed the following day her waters would be broken artificially, but was told the delivery unit was ‘too busy.’
On September 17, her waters broke naturally and she was informed that she was in a ‘queue’ for delivery.
But, by September 18, Miss Saunders was still in the queue and said she felt unwell, fearing she may be developing an infection, the inquest heard.
Repeated attempts were made by midwife Mel Brignall and Dr Peart, a fourthyear junior doctor, to arrange transfer to the delivery room. By the time Miss Saunders was taken to theatre at 15.22 on September 18, she had become septic and baby Scarlett’s brain had been starved of oxygen, the inquest heard.
Scarlett had to be resuscitated immediately after birth and was transferred to the hospital’s neonatal unit.
Further tests revealed that the newborn had showed no sign of brain activity since birth and her parents were informed the prognosis was poor.
Scarlett passed away on September 30. Recording a narrative conclusion, Fiona Borrill said: “The deceased would not have died if transfer had happened before 3.22pm on September 18 and if delivery had occurred before 4.13pm that day.”
In a statement following the inquest, Scarlett’s parents said: “The pain we feel knowing that Scarlett should be here but isn’t due to mistakes made by professionals you’re supposed to trust is heartbreaking.”