Inquest begins into death of newborn baby
CHANCE TO CHECK HEART RATE WAS MISSED AFTER MOTHER’S WATERS BROKE
AN INVESTIGATION has been launched into the death of a two-dayold baby after an emergency caesarean at Burton’s Queen’s Hospital.
An inquest into the death of little Sebastian Lefter heard how guidelines were not followed in the hours before his birth.
Mum Adina Netca’s waters broke at 1.55am, with guidelines stating a scan to listen to the foetal heartbeat should be carried out at that point. However, that scan was not carried out until more than 90 minutes later.
Midwives were unable to establish whether the pulse detected was Ms Necta’s or her baby’s.
Sebastian died on January 8, 2021, after he was found to have a low heart rate before he was born.
The first day of his inquest, held at South Staffordshire Coroner’s Court yesterday, heard how mum Adina Netca had raised concerns about giving birth naturally and wanted to speak to someone about having a c-section. Following an ultrasound scan on October 29, it was spotted the baby’s growth had started to tail off, and this was monitored by the hospital.
Patricia Paine, director of midwifery and divisional nurse at Queen’s Hospital, told how Ms Netca’s labour was induced on January 6, when she was 38 weeks and two days pregnant, and she was moved onto a ward. It was there she was cared for by an experienced midwife, and cardiotocography (CTG) scans to check the baby’s heartbeat were carried out, the last one being at 11.45pm.
At 1.55am, her waters broke and the midwife checked the fluid was clear and helped Miss Netca get cleaned up. However, contrary to guidelines, a CTG scan was not carried out to listen to the foetal heartbeat.
Director Ms Paine said: “The midwife did not have an explanation as to why she didn’t do this as she should have done. She was incredibly remorseful and upset that she hadn’t.”
It was not until around 3.30am that the CTG was carried out, but it was not clear whether the heartbeat detected was the baby’s or his mum’s, so another midwife was called in to help. Miss Netca, of Lichfield Street, Tamworth, was moved into a “left lateral position” and the director said at that “point they were not expecting not to find a foetal heartbeat”.
She said: “If they had looked for the heartbeat for three minutes they would need to get medical attention. It was six to seven minutes before the registrar was bleeped. The midwives became task-focused, trying to find a heartbeat, as they were not expecting not to find one and lost track of time.”
The first call-out was not done as an emergency to the consultant, but the second was. Miss Netca was quickly moved to the delivery ward and had a scan before being taken to theatre for a cesarean section.
Dr Banavathi responded to the emergency call from the midwives and quickly monitored the baby to see whose heartbeat they were picking up – the baby’s or the mother’s. It was found the baby’s heartbeat was low and the team proceeded to theatre for the operation, which had to be done within 30 minutes.
Sebastian was born with a low heartbeat and required resuscitation. It could not be said how long Sebastian’s heartbeat had been low as the CTG was not carried out when Miss Netca’s waters broke, the inquest was told.
Dr Banavathi told the hearing every minute the baby’s heartbeat was low increased the chance he would not get enough oxygen supply, so he needed to be delivered as soon as possible in the safest way as it could lead to hypoxic brain injury. Sebastian was born just after 4am on January 7.
Dr Sumant Kumar, a consultant pediatrician, was on his way to work when he was called in when the baby was just 19 minutes old. He said Sebastian was born in a poor condition, without a heart rate.
The inquest heard Sebastian was moved to specialist baby unit and it was decided when he was just two days old to “make him comfortable” after discussing stopping medical treatment with his parents. They then spent precious time with their boy before he died.
It was said that he had swelling to the brain and no sense of improvement. The autopsy found that Sebastian had a hypoxic brain injury.
The coroner is expected to give her verdict as to the factors that caused Sebastian’s death when the inquest continues today.