Baby death ‘not due to head cut’

Inquest’s natural causes verdict

A CORONER has ruled a prematurely-born baby died of natural causes despite sustaining a three-centimetre laceration to its head while a doctor tried to deliver the child during an emergency caesarean.

Assistant coroner Aled Gruffydd made the conclusion following a twoday inquest held at Swansea Civic Centre into the death of Millie-Rae Kimberly Dowd, who died shortly after being born at Singleton Hospital in Swansea at 6.15pm on January 12, 2017.

The first day of the inquest on Monday had heard how Millie-Rae’s mum, Stacey Mears, of Hendy, had a low-lying placenta while she was 26 weeks pregnant. The condition can cause severe bleeding before or during labour. She went to Singleton Hospital on January 12 for an appointment where she discovered her blood flow was normal with no drop but she then discovered that she was bleeding.

Miss Mears was placed on a labour ward where an emergency caesarean section was carried out.

Consultant Paul Flynn, who specialises in obstetrics, was in charge of delivering the baby and during the process of trying to do so, he cut through the placenta in order to minimise any blood loss.

The inquest heard a 3.5cm laceration had been caused with blood oozing from her head.

On Monday the inquest heard it was three minutes from the first cut to MillieRae being delivered.

Mr Flynn added: “I’m very sorry for the distress this has caused and my error has caused you but if I’d dawdled over the caesarean Millie would have succumbed to abruption and this would have been equally as bad.”

Millie-Rae died shortly after she was born and her cause of death was given as perinatal asphyxia, defined as a medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain.

Professor Gordon Vujanic, of the University Hospital of Wales in Cardiff, carried out the postmortem examination and said the baby’s death would have “undoubtedly” still happened regardless of her sustaining the head injury.

Questions were raised by the family of Dr Hajra Shafique, a registrar of obstetrics, as to whether action could have been taken an hour earlier due to Millie-Rae’s heart rate being monitored and found to be 80 beats a minute earlier in the day before delivery.

But it was heard a decision was made for her to be monitored closely and there was an intention for her to be delivered later that evening before the situation escalated.

Giving his conclusion, Mr Gruffydd said: “In this case the advised cause of death is one of natural causes.

“There was placental abruption, which led to perinatal asphyxia and, while the head injuries were traumatic, they were not the cause of death.

“I have to reluctantly agree with the evidence. The hospital has put in place a course of action to minimise risks in similar cases in future and Mr Flynn himself has warned other colleagues of the risks. This will not bring Millie back but hopefully prevent another family going through anything similar in future.”

After the case, the director of nursing and patient experience at Abertawe Bro Morgannwg University health board, Gareth Howells, said: “We again offer our sincere condolences to Millie’s family for their very sad loss. During an emergency situation our primary focus is to deliver the baby as rapidly as possible.

“In these circumstances there is a risk of unintended injury to the baby. We deeply regret that the circumstances surrounding Millie’s birth resulted in such a significant injury.

“While the cut did not cause her death we have put urgent actions in place to minimise the risk of this happening again.”