Doctors and midwives at Chesterfield Royal Hospital could not have prevented death of three-day-old baby, inquest finds

Elsie Rose Smith was three days old when she died at Leeds General Infirmary’s neonatal unit – where she had been transferred for emergency treatment following her birth at Chesterfield Royal Hospital.

On the final day of the inquest into her death on Wednesday, October 19, at Chesterfield Coroner’s Court, Area Coroner Peter Nieto heard that Elsie’s mother Imogen Smith, who was 18 at the time of her birth, was regularly attending antenatal appointments throughout her pregnancy.

Medical staff routinely undertook tests of Imogen’s health and Elsie’s development. They also performed urine tests for protein and blood pressure measurements – the results of which can indicate developing preeclampsia.

Initially, there were no concerns regarding Imogen’s pregnancy – but issues began to emerge from 36 weeks onwards. Imogen attended an appointment on October 8 and complained of feeling unwell and nauseous. She had raised blood pressure, although this reduced when checked again, and when Elsie was checked, her development, movement and heart rate were assessed as normal.

At this appointment, a doctor examined Imogen’s blood tests and raised the possibility of inducing her labour – after which another review of her condition was booked for two weeks' time.

On October 21, Imogen thought that her waters had broken and attended an antenatal clinic, where she was tested for signs of preeclampsia. She had raised blood pressure and increased protein in her urine, and was booked to attend the antenatal clinic again the following day – by which point she was 38 weeks pregnant.

A scan on October 22 showed that Elsie’s growth had tailed off, and the induction of Imogen’s Labour was scheduled for October 26 – the first available slot – with another preeclampsia review before then.

Imogen attended the review on October 24 and was seen by a midwife, who had a telephone consultation with a consultant obstetrician – but the obstetrician did not see and assess Imogen in person. The midwife who reviewed Imogen’s condition asked for her to be booked in for the next available slot for induction of labour – but this was already scheduled for October 26 – and Imogen was sent home.

On the night of October 25, Imogen had a restless sleep and experienced spasm-like sensations. Her mother rang the birthing centre, who advised that she take a hot bath before attending for induction at 10am.

She was admitted that morning and her signs of preeclampsia had persisted. Elsie’s heart rate was low, but she was assessed to be in her sleep cycle, and Imogen was encouraged to adopt a different position to wake Elsie.

Elsie’s heart rate initially improved, but shortly after, Imogen pressed her call bell as the monitor attached to her had lost Elsie’s heart rate.

The last reading that had been recorded for Elsie was about a minute old, and this raised no concerns. Imogen then said she needed the toilet and the monitor was removed. When it was reattached a few minutes later, Elsie’s heart rate was detected as being very low, indicating that she had become bradycardic.

An emergency Caesarean section was performed and Elsie was delivered four minutes later. The paediatric team attended and Elsie was found to be pale, floppy and unresponsive. Mr Nieto said she was in “very poor physical condition with clear signs of having experienced reduced oxygen supply and blood loss, and she had a very poor prognosis.”

Elsie was taken to the Royal’s neonatal unit for emergency treatment, before being transferred to Leeds. There was no improvement in Elsie’s condition and she sadly passed away on October 29.

Mr Nieto registered Elsie’s cause of death as severe hypoxic ischaemic encephalopathy – brain dysfunction caused by a lack of blood flow and oxygen to the brain.

The court heard that Imogen’s preeclampsia was considered clinically diagnosable by October 24. Although this was significant in terms of Elsie’s death, Mr Nieto did not register it as a direct cause.

After hearing evidence from the medical staff involved in caring for Imogen and Elsie, he said that her severe hypoxic ischaemic encephalopathy was “caused by feto-maternal haemorrhage, but the cause of the feto-maternal haemorrhage is unclear.” He added that Imogen’s preeclampsia “probably made a more than minimal contribution to Elsie’s death.”

Mr Nieto ruled that on the balance of probabilities he could not prove, from the evidence presented, that any acts or omissions from antenatal or medical staff that had contributed to Elsie’s death. He did, however, say that certain aspects of Imogen and Elsie’s care should have been handled differently – particularly relating to the review on October 24.

He stated that Imogen’s preeclampsia could have been diagnosed earlier by those who assessed her condition. Imogen’s review on this date was undertaken by a midwife, and although she telephoned a consultant, they did not perform a face-to-face review of Imogen – and admitted that this should have happened. Mr Nieto, however, said it was “speculative” to suggest that an in-person assessment would have prevented Elsie’s death.

The midwife indicated that Imogen’s induction should happen in the next available slot, but the court heard that there were no records as to whether the consultant made efforts to bring this forward. There was also no clear record of a preeclampsia diagnosis, and Mr Nieto considered whether this may have prompted closer attention.

Imogen’s issues the night before her induction were not highlighted to the day team at Chesterfield Royal Hospital. Mr Nieto said that, had these been communicated, the plans for Imogen’s induction may have been altered – but again ruled it was “speculative” to suggest this may have averted Elsie’s death.

Mr Nieto also questioned whether any issues during Elsie’s delivery had contributed to her death. A paediatric registrar did turn off a heater on a resuscitator, despite the temperature in the delivery suite being low for Elsie’s condition, which led to her needing to be warmed at the neonatal unit. It was agreed that this should not have been done, that the reason for doing so was unclear, and that it had a negative impact on Elsie’s body temperature. Mr Nieto ruled, however, that this was unlikely to have made a difference due to the severity of Elsie’s condition – but that it should have been on regardless.

The court heard that Chesterfield Royal Hospital has since made changes to its antenatal care. It now operates a prioritisation and review system for inducing labour, and uses a biomarker test for preeclampsia, designed to diagnose the condition earlier and allow for labour to be induced sooner. Records at the hospital are now predominantly electric – with multiple members of staff expected to record their decisions.