The Oxfordshire coroner, Mr Darren Salter today gave a narrative verdict after two days of hearing evidence on the circumstances leading up to the death of baby Harry Page, a twin son of Owen and Vicki Page, at the John Radcliffe Hospital on 16 December 2012.

Due to the unexpected nature of his death, the coroner opened an inquest on 3 January 2013 and investigations began. These included witness statements from those present at Harry’s delivery, a post mortem and associated investigations, and input from various experts.

The matter came before the coroner over the course of 26 and 27 November 2013 when he heard evidence from Owen Page, Harry’s father; Dr Anupama Ram Mohan, the obstetrician who delivered Harry; the other medical staff in the room and pathology experts. Having heard all of the evidence, the coroner recorded a narrative verdict that concluded that Dr Mohan, the obstetrician conducting the delivery, carried out manoeuvres to deliver the head referred to as the Burns Marshall manoeuvre and the Mauriceau Smellie Veit procedure.

Despite some dispute in the accounts given, the coroner found that the Burns Marshall manoeuvre was carried out twice with Harry’s feet held vertically above Vicki’s abdomen and on at least one of these occasions the feet went beyond the vertical and down towards Vicki’s abdomen. The significance of this is that, the baby’s position should not go beyond the vertical when the manoeuvre is performed because of the risk of damage.

The coroner found that Harry was delivered after the second attempt of this manoeuvre and after the use of a manoeuvre similar to a Mauriceau Smellie Veit procedure which was hands on and involved traction to Harry’s shoulders and neck.

The coroner concluded that the force used in these manoeuvres as performed caused impingement of the occipital bone against the maternal pelvis resulting in occipital diastasis. This is broadly defined as separation in the bones at the base of the skull causing a traumatic haemorrhage which, in turn, caused Harry’s death.

Harry Page’s birth

Harry Page was one of twins born to Owen and Vicki Page of Aylesbury in Buckinghamshire. This was their first pregnancy and all had gone well up to the time of Vicki’s admission to the on 14 December 2012 for induction of her labour. It was known that the second twin, Harry Page, was a breech baby and had been for some time.

Induction of labour did not commence until late in the day on 14 December and Vicki Page’s care came under the second on call registrar covering the night shift in the Labour Ward and the delivery suite that night.

Vicki’s labour progressed over the course of the evening and she was moved into theatre to allow for the possibility of a Caesarean section but, at about 0045 on the 15 December, a decision was made to proceed to delivery of the first twin, Ollie Page. Ollie was delivered by forceps and was born healthy and well at 0111.

After this, it was ascertained that the second twin, Harry Page, was still in the breech position. Dr Mohan decided to proceed to a breech extraction of Harry. While Harry’s body delivered easily, his head was not initially delivered. Dr Mohan made efforts to release his head and Harry was born at 0124. While he was initially in poor condition, he recovered quickly and Vicki and Owen Page left the theatre with both boys. Some time later that morning Harry Page’s condition began to deteriorate. Despite extensive investigations and treatment, he continued to deteriorate and died the following day, 16 December.

Vicki and Owen Page instructed Philippa Luscombe, partner in the clinical negligence team at Penningtons Manches LLP, and Simon Dyer of Cloisters chambers to represent them. In the interim, the hospital trust carried out its own internal investigation. In recognition of the support given to them by the hospital and the charity SilverStar, the Page family became involved in fund raising for the Special Care Baby Unit at the John Radcliffe Hospital.

Commenting after the inquest, Owen Page said: “The circumstances surrounding the delivery of Harry were at the time alarming to me. Since he died, we have wanted to understand what caused his death and whether it could or should have been avoided.

“The hospital staff who dealt with Vicki, Harry and me from the time that he became unwell did a fantastic job and did all that they could to save him. Since then, the Trust has carried out a full investigation into the method of Harry’s delivery and we were touched and appreciative of the thoroughness of this and the kindness and empathy that they all showed at the inquest.

“We found it very hard to listen to the evidence of how Harry was delivered and the differences in some of the evidence. However, we are glad to now understand what happened on the day and to have the coroner’s findings that the manoeuvres performed did cause Harry’s injuries that led to his death. We hope that the outcome of the investigation and the inquest will be that Dr Mohan, who is no longer employed by the trust, will have learned from this experience.”

Philippa Luscombe commented: “The death of Harry was a very tragic outcome from a happy pregnancy and a delivery that appeared to be going smoothly. Owen and Vicki have long been concerned about how Harry’s delivery was handled and the inquest has enabled them to get a better understanding of what happened and how his injuries were sustained.

“I would echo Owen’s comments that the Trust and its current staff have acted both professionally and with empathy throughout this case, carrying out a full investigation and being very honest with their evidence and views on what occurred and this has been very much appreciated and helped to make a very difficult couple of days a little easier.”