Death of baby ‘could have been prevented’
The death of a baby who died just four hours after she was born could have been prevented if an emergency ambulance had been made available to rush her to hospital when she took ill, a sheriff has ruled.
Nevaeh Stewart died three-and-a-half hours after she was born at Montrose Royal Infirmary’s community midwifery unit in September 2012, despite the efforts of midwives based there and
specialists who rushed from Dundee to her aid.
Her father Gary Stewart described the unit as an “emergency response blackspot” and accused NHS Tayside of “systemic failures” during a fatal accident inquiry being held at Forfar Sheriff Court.
A sheriff ruled Nevaeh had “simply languished” at the midwifery unit, receiving only “basic resuscitation” because NHS guidelines would not allow a blue light ambulance to be sent to collect her.
The dedicated neo-natal team allocated to cover Montrose at the time was on another job in Wick when she was born.
If Nevaeh had been a home birth and not born in the midwifery unit, a blue light999ambulancewould have been sent to pick her up. The inquiry – which lasted 14 days and heard from 16 expert witnesses – heard Nevaeh was born in a birthing pool at the Angus facility, but was immediately found to be “pale and floppy”. An ambulance from Ninewells Hospital took almost two hours to arrive, leading to accusations the standard of care given was “contributory to her death”.
Mrstewartsaid:“ibelieve that if NHS Tayside told parents the truth about
transfer times we would have made a different decision on obstetric care and we would have had timely access to specialist medical assistance if it was needed.”
His wife Kimberly added: “Had I been told in 2008 when I was pregnant with our second child that I’d have to wait an unlimited amount of time for specialist help if something went wrong with the birth, or after the birth, I think that’s enough information – and as a mother-of-one, and for the baby, I wouldn’t have risked it.”
Yesterday Sheriff Pino di Emidio agreed and ruled “more precise and evidencebased information about birth site choice” could help parents make a more informed choice. And he added that “provision of a 999 ambulance for retrieval of babies born unexpectedly unwell” could also have saved Nevaeh.
The sheriff further ruled that prospective parents should be told that there was “no good scientific evidence” that water births are as safe as giving birth out of water.
Mrs Stewart, 32, of Auchenblae, Aberdeenshire, said when Nevaeh – her fourth child – was born on 29 September 2012 she was “pale”and was immediately rushed away for treatment.
She was told to have a shower before a doctor entered and asked her if she wanted to sign a do-not-rescuscitate order.
She said she had been given just one chance to hold Nevaeh before she was taken away. Mr Stewart, 31, said he later discovered a neo-natal transfer unit could take “several hours” to arrive at midwife-led maternity units.
He said: “I presumed that if there was an emergency an emergency response team – a flying squad – would be brought in to fix the situation. In community midwife units, there is no emergency response and you may have to wait up to six hours as there is no emergency squad to go to any unit in Scotland.”