Inquest report published after death of baby following forceps delivery

A couple whose twin baby boy died shortly after being born have called for an independent inquiry after doctors at a Lincoln hospital were accused of covering up a series of mistakes that led to the death in September 2013.

Stuart Fisher, senior coroner for Central Lincolnshire ruled that Thor Dalhaug died an hour after birth at Lincoln County Hospital from fatal brain damage due to errors by medical staff.

The inquest report found that an unsupervised junior doctor used forceps in an ‘unorthodox and unacceptable’ way to deliver Thor.

The hospital has just been taken out of ‘special measures’. United Lincolnshire Hospitals NHS Trust was put on a turnaround regime almost two years ago due to concerns over high death rates.

However Rolf and Michelle Dalhaug, Thor’s parents, told the Mail on Sunday that the report revealed that staff had behaved ‘appallingly’ over their son’s death in 2013.

Rolf Dalhaug said:

“Michelle and I tried unsuccessfully to have a family for over seven years. After many failed attempts at IVF when we found that Michelle was pregnant we where overjoyed, more so when we found we where having twins - finally the family we always wanted.”

Thor’s head became stuck during a Caesarean delivery, junior surgeon Dr Deniz Al-Hirmizy having tried to free him with her hands then resorted to forceps.

Thor died an hour later from brain damage as a result of the attempts to free his head.

While Dr Al-Hirmizy stated she had ‘experience of caesareans’, she claimed she had been ‘unsupervised’, wrote Mr Fisher.

Surgeons ‘neglected to make a full note of the circumstances’, he found. ‘In particular’, he wrote, a doctor ‘was advised to amend the caesarean pro forma, to include the fact that forceps were used’.

But this doctor was ‘dissuaded from doing so by senior management as a result of concerns as to how this would be perceived’.

Mr Dalhaug, told the Mail on Sunday: ‘The Trust have acted appallingly, causing our family great hardship. We accept that accidents can, do and will happen. What we do not accept is their failure to be honest, their failure to learn and their failure to act.’

Dr Suneil Kapadia, the Trust’s medical director, apologised to the Dalhaug family and said it would pay them compensation.

Suzanne White, a partner in the clinical negligence team at law firm Leigh Day, said the family were considering legal action against the doctor and the hospital.

She added: ‘Despite representing families at inquests for over 15 years, I am astonished by the circumstances surrounding baby Thor’s tragic death.’

Mr Dalhaug concluded:

“A parent should never have to endure the death of a child but to add insult to injury the ULH Trust failed to investigate his death on multiple occasions adding significant additional distress, anguish and headache to our family at an already difficult time, needlessly drawing out the inquest to over 15 months.

“We are appalled at the evidence which has come to light during the lengthy inquest. Based on this it is our view that Thor was killed through preventable events at the hands of a registrar who took it upon herself to attempt multiple unorthodox, dangerous and unacceptable procedures to delivery him directly resulting in his death.

“We will ensure that the appropriate action is taken to hold those at fault accountable for their actions and to send a message that this kind of disregard for investigating serious deaths is not acceptable.

“We would like an independent investigation into the circumstances of Thor’s death as we are greatly concerned that the Trust may have a history of these systematic failures.

“Michelle and I would like to pay tribute to the midwifes and support staff who looked after us during our continued stay in hospital. Their kindness and support was a great comfort to us at a very difficult time.”