Death of baby at Sherwood Forest Hospitals NHS Trust “contributed to by neglect,” coroner finds

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A baby who died from a brain injury following a delayed labour and delivery was failed by staff at Sherwood Forest Hospitals NHS Trust, a coroner has concluded.

Arlo River Phoenix Lambert died on March 9, 2023, at King’s Mill Hospital, at five days old.

The coroner found that Arlo’s death was “contributed to by mismanagement of labour and multiple missed opportunities to have expedited his delivery”.

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She concluded that neglect contributed to Arlo’s death, which came from “a failure to follow trust guidance”.

Arlo River Phoenix Lambert.Arlo River Phoenix Lambert.
Arlo River Phoenix Lambert.

Miss Lambert, Arlo’s mother, was induced at 40+2 weeks, and following spontaneous rupture of membranes (SROM), she was left for 17 hours without any attempts made to progress her labour. This gave time for the risk of infection to materialise, the coroner found.

The coroner reported findings of staff failure to tackle care plan and found evidence of “multiple missed opportunities to have expedited Arlo’s delivery which would probably have prevented his death.” She has issued a Prevention of Future Deaths Report.

Since Arlo’s death Miss Lambert has suffered from post-traumatic stress disorder (PTSD).

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Furthermore, the coroner also made a complaint to the General Medical Council in relation to the actions by the Specialist Registrar.

King's Mill Hospital, Sutton.King's Mill Hospital, Sutton.
King's Mill Hospital, Sutton.

In oral evidence, they said that they would “cross [my] fingers behind my back and hope and pray the mother would go into labour” instead of implementing an appropriate care plan.

A post-mortem found that Arlo’s brain showed evidence of hypoxic-ischaemic injury.

This is where brain cells die because of a period of time spent without adequate oxygenated blood supply, which can occur as a result of delayed delivery following fetal distress.

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The coroner reported multiple failings from pregnancy scans to birth.

Queen's Medical Centre, Nottingham.Queen's Medical Centre, Nottingham.
Queen's Medical Centre, Nottingham.

If Miss Lambert had not been offered induction of labour at 40+2 weeks, she would likely have gone into labour spontaneously, the coroner stated, and “her previous labours suggest she would not have faced any challenges delivering Arlo”.

From when she arrived under the care of Sherwood Forest Hospitals NHS Trust, numerous delays in commencing the induction led to the tragic outcome. Poor communication and a shortage of staff contributed to delays in developing a plan for delivery.

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At 11.33am March 3 2023, the baby’s head was found to be presenting high in the pelvis, but there was a missed opportunity to consider mode of delivery and to have counselled mum on the risks and benefits of continuing with induction of labour, or caesarean delivery, in accordance with national guidance, the coroner found.

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At this point, CTG monitoring was discontinued which was also against national guidance, so the midwives were unable to continuously monitor for any signs of fetal distress.

At 5pm, after being asked to confirm the position of the fetus with an ultrasound scan, it was the registrar who wrote a delivery plan without consulting Miss Lambert’s wishes and without knowledge of her situation, according to the report.

If the induction of labour policy had been followed when labour was not established two hours after SROM, delivery by either method “would probably have avoided his death”, she concluded.

Moreover, at the ward round at 9.43pm there was a communication failure between the midwife and obstetric team to understand that there had been blood stained liquor.

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It wasn’t until 3.58am on March 4 that doctors decided to proceed to a category 1 caesarean section for suspected placental abruption.

At just before 4.30am, Baby Arlo was delivered by a difficult caesarean section due to his position, following a delay by the midwives recognising that there were complications and alerting the obstetric team for assistance.

Baby Arlo was in a compound position with both a leg and an arm above his head.

It was apparent on delivery that there had been a placental abruption given the volume of blood and clot within the uterus.

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Arlo was transferred to the neonatal unit at the Queen’s Medical Centre for specialist care, but he sadly passed away five days later.

Had Arlo been delivered sooner, he “would more likely than not have survived,” the coroner concluded.

NHS Trusts are under pressure to improve services following a series of high-profile scandals in recent years.

A recent Birth Trauma Inquiry found that poor maternity and postnatal care is “tolerated as normal” and called for an overhaul in the face of overwhelming evidence of medical negligence.

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Chantae Clark of Tees Law, acting for the family, said: “These tragic events were preventable if Sherwood Forest Hospitals NHS Trust had followed guidance and acted on the warning signs in the hours before Miss Lambert’s labour.

“It is hard to believe that in such an advanced healthcare system, a mother should suffer the treatment that she did and that a baby should die because of neglect.

“The immense toll on Arlo’s family shows the devastating impact of these failings. It is of some comfort to the family that the coroner has carried out such a robust investigation and has found evidence of neglect and issued a Prevention of Future Deaths Report.

“The family sincerely hopes that the Trust implements urgent changes to prevent another avoidable disaster befalling any other family.”

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Your Chad approached Sherwood Forest Hospitals for a comment on the report.

Dr Simon Roe, Acting Medical Director at Sherwood Forest Hospitals, said: “We would like to express our deepest condolences and our unreserved apologies to the family of Arlo Lambert for their loss.

“As a trust, we are committed to providing outstanding care to all of our patients and we’re sorry that we have not been able to provide that on this occasion.

“It is right that cases like these are properly reviewed to strengthen our commitment to providing the best possible care to local families and we’ve already introduced some changes to our guidelines to ensure we implement immediate learning.

“We will consider the full findings of the coroner’s Prevention of Future Deaths Report (PFD) to help improve the care we provide in the future.”

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