FROM STILLBIRTH TO SEPSIS, TRAGIC LITANY OF FAILURE

A 40-hour-old girl died from sepsis at Caithness General Hospital on September 3, 2015. The baby’s sudden death was the catalyst for NHS Highland’s investigation into maternity services there. It was concluded that she died of an infection ‘that was certainly capable of treatment’ and ‘on the balance of probability earlier treatment of infection would have led to the baby’s survival without impairment’. A young mother suffered a stillbirth while ten days overdue. Her pregnancy had been classified ‘high risk’ with complex medical and obstetric problems. Yet there were ‘particular problems’ with access to accommodation for her at the specialist unit at Raigmore Hospital, Inverness, which meant that she had to return to Caithness with ‘no plan for induction of labour’. A mother went into labour after reaching ‘term’ (37+ weeks) but her baby died soon after birth. It was concluded that growth restriction ‘does not seem to have been considered’ despite the baby having been noted antenatally to have been on the sixth centile of a customised growth chart. It was concluded that an ‘avoidable factor’ and ‘different management’ ‘might have made a difference to the outcome’.

A newborn baby died after being born unexpectedly at home. The review found ‘there appears to have been no recognition of the risk of preterm labour’ and this resulted in a birth at home. It was concluded that an ‘avoidable factor’ and ‘different management’ ‘might have made a difference to the outcome’.

A mother suffered a stillbirth at 25 weeks. Supervision and documentation during her labour was found to be ‘sub-optimal’. There was also a delay in providing a second opinion to confirm the death of the foetus, which represented a ‘poor standard of care’. It was concluded that an ‘avoidable factor’ and ‘different management’ ‘might have made a difference to the outcome’.