Fatal Accident Inquiry into the death of baby N

The following is a summary of the determination of Sheriff Pino Di Emidio in the application of the Procurator Fiscal for the District of Forfar in respect of the death of N, who died on 30 September 2012 at the Community Maternity Unit in Montrose Royal Infirmary.

A Fatal Accident Inquiry into the death of a baby at less than three-and-a-half hours after she was born in a community maternity unit has found that the failure to provide a 999 ambulance service to transfer unexpectedly unwell babies to hospital for specialist care was a defect in the system of working which contributed to the death. 

The baby “N” was born at 5.10am on 30 September 2012 in a birthing pool at Montrose CMU, but died at 8.35am that day, with the cause of death certified as peripartum hypoxia. 

Following an Inquiry at Forfar Sheriff Court, Sheriff Pino Di Emidio found that there were a number of reasonable precautions whereby the death might have been avoided, and made further recommendations arising from the evidence led at the Inquiry. 

The Inquiry heard that at birth N was “pale and floppy” with no respiratory effort and attempts were made by the midwives to resuscitate her, before contacting the senior registrar on duty in the Neonatal Unit at Ninewells Hospital in Dundee. The senior registrar requested an ambulance to be sent to retrieve N and instructed the midwives to continue neonatal resuscitation. 

However, the specialist neonatal ambulance which covered Ninewells was not available as it had been despatched to an emergency in Wick. 

An ambulance was ordered for staff at Ninewells to undertake the necessary transfer of N, but when it arrived at the neonatal unit, at about 6.05am, it had to be sent back as it did not have an incubator and was considered unsuitable to transfer N, so a second ambulance was requested. 

At about 06.35am the second ambulance arrived and the neonatal team left shortly thereafter, but in the meantime N’s condition had deteriorated, with midwives noting “CPR commenced as HR absent” at about 7.10am. 

The neonatal team arrived five minutes later and continued efforts at resuscitation, but N’s heart rate could not be maintained despite their strenuous efforts and she was pronounced deceased at 08.35 after the parents agreed that they should stop resuscitation measures.  

The consultant in charge of the neonatal unit at Ninewells had requested a police vehicle to transport him to Montrose CMU, but he was advised of the death while en route. 

Sheriff Di Emidio found that the death might have been avoided by certain reasonable precautions, including the provision of more precise and accurate evidence-based information about birth site choice to the prospective parents during the course of the pregnancy in order that they might make an informed choice of birth site. 

In particular the following information ought to have been provided within the scope of a structured conversation with midwives which was adequately recorded: 

  • although such events are rare, and despite careful risk assessment designed to ensure that only low risk mothers give birth in a midwife led remote CMU like Montrose, from time to time babies are born in CMUs unexpectedly unwell at term and may require urgent specialist treatment;
  • in some cases delay in delivering treatment to such an ill new born baby may significantly reduce prospects of success and even lead to the death of the baby;
  • the facilities available at a midwife led remote CMU like Montrose in the event that the baby was born unexpectedly unwell at term are limited in nature as there is no specialist obstetric or paediatric care available on site;
  • if a baby is born unexpectedly unwell at term in an Alongside Midwifery Unit (“AMU”) or a specialist hospital like Ninewells Hospital, Dundee (“Ninewells”) she will have access to specialist care within a few minutes;
  • a seriously unwell baby would have to be taken to the specialist obstetric or paediatric care units at Ninewells;
  • there is no specialist recovery service that can be deployed at short notice to take a seriously unwell baby to specialist obstetric or paediatric care; and
  • the period of delay that may occur in taking a seriously unwell baby to specialist care or in specialist assistance arriving at Montrose CMU can extend to several hours. 

The provision of a 999 ambulance for retrieval of babies born unexpectedly unwell within the Montrose CMU as a primary option as part of the NHS Tayside (NHST) guidelines for neonatal transfers was a further reasonable precaution identified. 

The Sheriff concluded that the failure to provide a 999 ambulance service for the retrieval of babies born unexpectedly unwell within the Montrose CMU as a primary option as part of the NHST guidelines for neonatal transfers was a defect in a system of work that contributed to the death. 

Sheriff Di Emidio’s determination stated: “When N was unexpectedly born pale and floppy it happened to be the case that the dedicated neonatal ambulance that covered Ninewells and outlying CMUs was away in Wick. Therefore Ninewells had to put together an ad hoc arrangement to get N to specialist care. The lack of a blue light ambulance option contrasts starkly with the position of an unstable neonate born at a home birth. The situations are comparable but in one case a blue light ambulance would be summoned straight away. The guidelines then in force were adhered to. This meant that the unstable neonate simply languished at the Montrose CMU with only the basic resuscitation care that could be provided by the midwives who did their best in the circumstances. 

“Although none of the experts could say that N would have survived in the longer term if she had had prompter specialist treatment, she might have done. If she had been born in the AMU at Ninewells she would have been in specialist care area within a very few minutes, that is, at the very start of the time critical period. I think it inconceivable that upon birth the specialist team would simply have washed their hands of N because they did not think she could survive. I have no doubt that strenuous efforts would have been made to save her with all involved proceeding on the basis that she stood a chance of survival. Although this cannot be said with any degree of certainty, I consider that there is at least some reasonable prospect that her death might have been avoided if she had had specialist treatment at the start of the time critical period or at some stage along that continuum by virtue of having been brought to Ninewells expeditiously.” 

The Inquiry was advised that since early 2016 a video conferencing link between the NICU at Ninewells and Montrose CMU has become available. This has allowed for greater information to be available to the specialist practitioner at Ninewells. Though the picture quality is moderate it is possible to observe the sick newborn so that the specialist clinician at the unit at Ninewells can observe the baby. This allows some appreciation of the colour of the baby and improves understanding of the baby’s condition. 

Special harnesses are now also available to allow a small baby to be strapped securely in an ambulance in the event that there is a need for emergency transfer to Ninewells. 

The full determination can be accessed via the Scottish Courts and Tribunals Service website.

Notes to editors

This summary is provided to assist in understanding the sheriff’s determination. It does not form part of the reasons for the decision. The full determination is the only authoritative document.

The parties have been anonymised for data protection reasons. However, there is no contempt of court order in place in respect of this case and therefore the normal reporting rules apply.