A newborn baby died due to the gross failure of three midwives to provide basic medical care, a coroner has ruled.
Ida Lock was born at the Royal Lancaster Infirmary (RLI) on 9 November 2019 but died a week later after suffering a serious brain injury due to a lack of oxygen.
After a five-week inquest at Preston County Hall, coroner James Adeley concluded that Ida’s death had been caused by the midwives’ failure to deliver the infant “urgently when it was apparent she was in distress” and contributed to by the lead midwife’s “wholly incompetent failure to provide basic neonatal resuscitation”.
He said there had been eight missed opportunities “to alter Ida’s clinical course”.
The inquest heard that Ida was transferred to the intensive care unit at Royal Preston Hospital’s neonatal unit, where she died on 16 November 2019.
The hearing previously heard that an April 2020 report from the independent Healthcare Safety Investigation Branch (HSIB) had identified numerous failings in Ida’s care which had contributed to her death.
The review said midwives failed to identify an abnormally slow foetal heart rate after Ida’s mother, Sarah Robinson, attended in early labour.
After Ida was born there was ineffective resuscitation, the HSIB concluded.
But an earlier internal “root cause analysis” from the hospital in January 2020 found no issues and praised the “great cohesion and communication” shown by staff in the delivery suite.
After reading the “night and day” contrasting reports, Ida’s parents Ms Robinson and Ryan Lock complained to University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT), which runs the hospital.
Delivering his conclusion, Dr Adeley, said: “Ida was a normal child whose death was caused by a lack of oxygen during her delivery that occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress.”
And he noted that her death was contributed to by the lead midwife’s “wholly incompetent” failure to provide basic neonatal resuscitation during the first three-and-half minutes of her life.
This, he said, further contributed to the infant’s brain damage.
The senior coroner also criticised the hospital’s investigation into Ida’s death, calling it a “damning indictment of an ineffective, dysfunctional and callous system that has failed this family at every opportunity”.
UHMBT was the subject of a damning report in 2015 that found a “lethal mix” of problems at another of its maternity units at Furness General Hospital that led to the unnecessary deaths of 11 babies and one mother between 2004 and 2013.
The Morecambe Bay investigation, chaired by Dr Bill Kirkup, uncovered a series of failures “at every level”, from the unit itself to those responsible for regulating and monitoring the trust.
In a statement, Tabetha Darmon, chief nursing officer of UHMBT, said: “Losing a child is tragic and our heartfelt condolences go out to Ida’s parents, family and loved ones. We are truly sorry for the distress we have caused.
“We accept that we failed Ida and her family and if we had done some things differently and sooner, Ida would still be here today.
“We also acknowledge the additional upset caused to Ida’s parents and family as a result of the way investigations into Ida’s death have been conducted since 2019.
“For that, we are truly sorry.
“We take the conclusions from the coroner very seriously and have made a number of the improvements identified during the inquest.
“We are carefully reviewing the learning identified to ensure that we do everything we can to prevent this from happening to another family.”
Additional reporting by PA Media.
