Multiple factors led to 5-day-old baby’s death after hospital transfer
ESSENTIAL NEONATAL EQUIPMENT WAS NOT ALWAYS AVAILABLE, INQUEST TOLD
THERE were a number of factors that contributed to a baby’s death at a Nottingham hospital, an inquest has heard.
Arlo Lambert was five days old when he died at the Queen’s Medical Centre on March 9, 2023, after being transferred from King’s Mill Hospital following his birth on March 5.
The hearing, held at Nottingham Council House on Tuesday, was told that prior to labour, Arlo’s mother, Annabel Lambert, was correctly riskassessed and received adequate neonatal care, with additional investigations carried out as clinically required.
Following a spontaneous rupture of membranes, the baby’s head remained high in the pelvis, and coroner Laurinda Bower said an obstetric review was not requested. The review would have considered all the clinical factors, produced a plan of care, and assessed whether a caesarean birth was required.
When the spontaneous rupture of membranes occurred during the induction of labour, the decision was made to delay augmentation (the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labour) until the next morning without a clinical rationale.
This meant the pregnancy continued without continuous monitoring of the foetal heart rate. A compound presentation was also queried on vaginal examination by the midwife, which was followed by an ultraat sound. This delayed the confirmation of the compound presentation, which means that an extremity presents alongside the baby closest to the birth canal. Foetal bradycardia was also recognised as present but escalation to the midwifery coordinator and then the obstetrician was not undertaken.
The inquest was also told there were several occasions when essential equipment required for providing resuscitation and urgent neonatal care was unavailable, which meant that staff were having to think of workarounds while trying to provide care.
Baby Arlo received antibiotics at around two hours old due to the ongoing stabilisation process, despite national guidance recommending the administration of antibiotics within one hour of the decision to treat the baby.
The transfer from King’s Mill Hospital to Queen’s Medical Centre was delayed due to difficulty in stabilising and securing the baby’s airways, which ensured the best outcome during the transfer to NICU (neonatal intensive care unit). However, the court heard that discussions between the multidisciplinary teams at the two trusts took place frequently, allowing the QMC to prepare for Arlo’s arrival.
Mohammad Haini, consultant paediatric and perinatal pathologist St Thomas Hospital performed the post-mortem examination on April 3, 2023. Dr Haini was the first witness to give evidence during Tuesday’s hearing. He said: “The external examination of the baby showed signs of recent medical intervention and no other significant abnormalities.
“I have performed an internal examination of the baby and organs showed no congenital malformations.
“The main findings were hypoxicischaemic brain injury [a brain injury that happens when a baby’s brain doesn’t receive enough oxygen during delivery] and acute chorioamnionitis with foetal inflammatory response.”
The placenta was also examined by Dr Haini and showed evidence of inflammation and acute chorioamnionitis in the membranes.
Chorioamnionitis is an infection of the amniotic fluid and tissue that surround a foetus during pregnancy. An inflammation of the umbilical cord was also discovered.
The maternal and foetal inflammatory response evidenced by the acute chorioamnionitis with foetal inflammatory response put the baby under stress and triggered the series of events that led to the hypoxic brain injury.
Coroner Bower told the hearing that Ms Lambert had given birth normally “a number of times” before baby Arlo. She said: “He was a normally formed male baby. No evidence of malformation, no evidence of underlying genetic conditions or complications [were found].”
The inquest continues.