Baby boy died during birth complications at Sunderland Royal Hospital, inquest hears
A Sunderland baby’s tragic loss during birth is to be raised with the Government to prevent further deaths after an inquest heard talks could have been held to offer his mum a Caesarean section.
The boy was unable to be revived after a 9-minute delay caused by shoulder dystocia, when the baby’s shoulder becomes stuck, during labour in spring 2020.
A consultant-led plan was put in place by Sunderland Royal Hospital when his mum’s pregnancy was classed as high-risk, including extra scans, with the last unable to go ahead due to Covid guidance.
Sunderland’s senior coroner Derek Winter said while it was clear the risk of shoulder dystocia had been discussed, he agreed with expert witness Professor Gupta who said talks could have been held about the benefits and risks of a Caesarean section – although he noted he could not tell if it would have made a difference to her decision.
He noted South Tyneside and Sunderland NHS Foundation Trust had already “made improvements for the better” to its guidance and required no Prevention of Future Deaths Report.
However, to ensure hospitals around the country are aware such conversations should be held, he would write to Health Secretary Sajid Javid to highlight the issue.
Mr Winter said the birth had a “harrowing impact” on the mum and was “truly awful”, explaining after forceps were used to deliver the boy’s head, the staff realised it would not be easy to complete his birth.
The team, which had practised carrying out manoeuvres to deal with shoulder dystocia, made “extensive attempts” to save the baby.
Professor Gupta’s evidence at the Sunderland Civic Centre hearing noted a gestational diabetes check was given at 23 weeks, within the guidance, when he would have preferred to carry it out at between 26 and 28 weeks – a post-natal test indicated she had the condition.
Mr Winter acknowledged while the boy had been a bigger baby, which can be the result of gestational diabetes, shoulder dystocia can happen in any delivery.
"I feel there was still a need for an alternative, viable delivery, an elected Caesarean, being put to [the mother],” he said.
“I agree with Professor Gupta, there was a crucial missing discussion which could have led to a more detailed discussion.
"It is impossible to say what decision would have been made and we know what the tragic outcome was for the baby, but as Professor Gupta said, if there had been a Caesarean section, it is not beyond the possibility this would have led to the baby being born alive, without a disability.”
He concluded the baby, who the Echo has chosen not to identify, died from a complication of childbirth and thanked all those involved, particularly the baby’s family, for their “dignity and co-operation” during the three-day hearing.
Melanie Johnson, the trust’s Executive Director of Nursing, Midwifery and Allied Health Professionals, said after the inquest: “On behalf of the trust I would like to offer my heartfelt condolences to the family for the very tragic death of their baby.
“We are pleased that the coroner recognised the significant work that trust has done to learn from this very complex case and address the issues identified.
"We also welcome the coroner’s action to seek clearer national guidance.”