Ayla Newton, a baby girl, might not have died if the obstetrician in charge of her birth had listened to the midwives a coroner's inquest determined. The midwives told the doctor they were worried about the baby's condition and urged him to perform a Caesarean section. He delayed, and Newton was born dead.
The coroner's findings indicated that emergency procedures were not implemented, resulting in Ayla being born in a precarious condition. Flaccid, pale, with poor respiratory effort, and seizing, she was obviously not a normal newborn.
Sadly, the newborn died 13 days after birth, following the transfer to a specialized facility for advanced medical care.
Dr. Malcolm Griffiths, in his capacity as an expert witness, underscored the importance of a specific reading taken from the cardiotocograph (CTG) at 3:12 AM. He called this recording, narrative, or representation of the CTG graph, "so grossly abnormal that it should have necessitated an immediate Caesarean section."
After the finding, Ayla's grieving parents said they were profoundly disappointed. They still have received no apology from the hospital. She said we believe that not one person can justly carry the blame; this is a systemic failure that has yet to be fully acknowledged by the hospital. We believe it's time for the hospital to own up to this and give us an explanation we can understand.
The inquest, carried out over two days in Blackpool, Lancashire, showed that the CTG monitoring equipment had significant cardiac irregularities almost 90 minutes before Ayla's birth. But locum obstetrician Dr. Muhammad Sandow didn't do the right thing under the misbegotten belief that those abnormal readings would sort themselves out.
Coroner Margaret Taylor delivered her findings on Tuesday: 'The clinical decision of (Dr Sandow) was incorrect. The safest option would have been to proceed to a Caesarean section.'
Ms. Lord, 27, and her partner, Mr. Dayle Newton, 36, were told by Coroner Taylor that the delays leading up to the eventual Caesarean section probably caused the poor outcome and death of their daughter.
The coroner emphasized that Ms. Lord had a real expectation to come back home with a healthy child after a normal, low-risk, uneventful pregnancy before she went into labor at Blackpool Victoria Hospital. Unlike most mothers, she went into labor with no prior knowledge that there was anything wrong with her baby.
In delivering a narrative verdict, the coroner did not issue a finding of neglect against the Blackpool Teaching Hospitals NHS Trust concerning the circumstances surrounding Ayla's birth on January 26, 2023. The coroner asserted that the decision to delay performing a Caesarean section was 'not evidence of a lack of basic care.'
She remarked, 'It requires specialist knowledge to interpret CTG results, and it is an art form of sorts.
Eleanor Rostron, representing Ayla's parents, read a statement that asserted:
'Maternity staff should be aware of the importance of carefully monitoring both mother and baby up until a baby is safely delivered.'
In real time, the heart rate of Ayla was shown, and it was clear from the very beginning and for a long time that the results were grossly abnormal. This was a situation that should have called for an emergency medical intervention to deliver Ayla and for the medical team to follow national guidelines in making that emergency intervention.
The concerns that were raised repeatedly by several midwives were ignored. The midwives neglected to elevate their concerns to the overall consultant in charge.
The inquest established that Dr. Sandow did not see eye-to-eye with midwives Jennifer Fogg and Mandy Benton over the CTG readings. Both midwives were worried about the numbers; however, neither took their worries to the actual boss of the ward, Dr. Reem Nasur after Dr Sandow had 'reassured' them he had seen similar results before.. According to the midwives, after Dr. Sandow had spoken with them, they felt much better about the outcome and were content to keep things as they were on the ward.
During the inquest, Dr. Sandow was clearly emotional, breaking down and crying as he expressed his regrets to Ms. Lord and Mr. Newton for the death of Ayla, who went on to die at Royal Preston Hospital.
Without tearful emotion, he told the couple: "I should not have waited. I want to extend my condolences to you now."
A Prevention of Future Deaths Report not issued by coroner Taylor which would have required urgent action, after being assured by counsel for the hospital trust, Nichola Halpin, and senior obstetrician Eric Mutema, that it had introduced new guidelines.
https://www.judiciary.uk/courts-and-tribunals/coroners-courts/reports-to-prevent-future-deaths/
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