He identified a failure by the hospital to recognise the seriousness of Ava's condition and a delay in carrying out an emergency caesarean section resulting in a lost opportunity to render to her further medical attention.
Ava Mae Charlton was born at Milton Keynes Hospital on 16 September 2009 and died within an hour of her birth. The hospital classified her death as a 'stillbirth' even though there were signs of life after birth. Ava's death was not originally reported to the Coroner because the Coroner has no jurisdiction to investigate a death classed as a 'stillbirth'.
Ava's parents, Emma and Terry Charlton, challenged the classification of 'stillbirth' but the hospital would not accept that Ava was born alive until late last year (2011) when they changed their opinion following a case review conducted by the newly appointed Head of Midwifery. That review confirmed that there were signs of life after birth and Ava's death should not have been classified as 'stillborn'. The hospital subsequently referred the death to the Coroner and following a review HM Coroner determined that there needed to be an inquest which heard evidence from the midwives and clinicians involved.
Emma Charlton was admitted to Milton Keynes Hospital maternity unit on 14 September 2009 at 38 weeks gestation with pre-eclampsia. Prior to her admission she had an MRI scan because there was a concern that the size of her pelvis would make natural delivery difficult. The MRI scan showed that she had a 'borderline pelvis' meaning that a natural delivery would be risky. However, Emma was not informed of any risk associated with delivering naturally nor was she given the option of a caesarean section.
Had Emma been advised of the 'borderline pelvis' result and the risks of natural delivery, she would have elected to have a caesarean. Instead, she was induced and tried for a natural delivery. The induction did not work but Emma suffered bleeding and Ava became distressed. The Coroner found that there was a failure to properly interpret CTG (cardiotocography) traces or recognise that Ava's condition had deteriorated and there was a delay in performing an emergency caesarean section. That was eventually carried out at 01:50 on 16 September 2009 and Ava was born at 01:53 in a very poor condition. Despite resuscitation she sadly died within an hour of her birth.
The Coroner accepted the evidence of the neonatologist that the biggest contribution to Ava's death was a chronic hypoxic event from 00:30 hrs and he accepted the evidence of one of the treating consultant obstetricians that the decision should have been made to perform an emergency caesarean section at that time. The decision was not in fact made until some 28 minutes later and the go ahead was only confirmed at 01:20. Had the decision to deliver via emergency caesarean section been made at 00:30 on the balance of probabilities Ava would have survived.
The Coroner delivered the following narrative verdict:
'Ava Mae Charlton was born by emergency caesarean section at 01:53 on 16 September 2009 and died at 02:25 the same day at Milton Keynes Hospital. Her mother had been admitted to the hospital on the 14 September 2009 with pre-eclampsia. She underwent induction of labour prior to the emergency caesarean section. Ava became distressed at 00:25 on the 16 September and there was a failure to recognise the seriousness of her condition and a delay in carrying out the emergency caesarean section that resulted in a lost opportunity to render to her further medical attention.'
Furthermore, in his summing up, Mr. Osborne confirmed that as a direct consequence of Ava's death he now requires all stillbirths and neonatal deaths in his jurisdiction to be reported to him so that he can determine whether the baby was stillborn or whether it was a neonatal death and whether an inquest should be called.
Following the inquest, Emma and Terry Charlton said:
'The inquest at least gave us some answers to our questions about how the pregnancy was managed and the death of our baby daughter Ava Mae on 16 September 2009 at Milton Keynes Hospital. We're still bitter about the fact that it took more than two years for the Trust to concede that Ava Mae was not 'stillborn' as they originally claimed (and as we questioned immediately when we were handed the certificate). We're also dismayed by the fact that several key witnesses, such as Professor Lynch, Emma's consultant, could not apparently find the time to attend the proceedings.'
This is not the first case where Milton Keynes maternity unit has been forced to face questions about its practice of declaring babies 'stillborn', thereby avoiding the need for the official scrutiny of an inquest. However, getting a detailed explanation of exactly what happened, what went wrong, what could have been done better and why Ava Mae was declared 'stillborn' when the medical records clearly showed there were signs of life after birth was Emma and Terry Charlton's driving motive in pushing for an inquest to be held.
Emma and Terry added:
'HM Coroner's observation that, if an emergency c-section had been performed sooner in accordance with timescales suggested by NICE guidelines, Ava would be with us today was particularly distressing. Our only other regret is that, because of the initial refusal by the hospital to accept that our daughter was in fact born alive, years have passed meaning that the recollection of those witnesses who did attend was not as precise as it would have been immediately after the event. Our recollection today is as crystal clear as it was on 16th September 2009. Hopefully the verdict of HM Corner will be taken to heart and acted upon by the hospital so that other parents will be spared the pain and emotional turmoil that we have had to endure simply to discover the truth about why our little baby girl's life was so short.'
Emma and Terry are represented by Phil Barnes, Partner of Shoosmiths.
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