The child’s parents, who we will refer to as Mrs and Mr B, have received a six-figure settlement after Chelsea and Westminster Hospital NHS Foundation Trust admitted breaches of duty in relation to the management of Mrs B’s labour and delivery of her baby girl (referred to as baby C) in summer 2019.

When her waters broke, Mrs B was seen at home by a midwife who told her to go to hospital in 24 hours for induction of labour at 36 hours However, when Mrs B went into hospital the next day, she was told to come back 12 hours later for induction.

Mrs B subsequently returned to the hospital for an induction of labour. During the course of her labour, baby C was not tolerating Syntocinon well. The clinicians decided on a vaginal delivery, however, Mrs B says she would have opted for a caesarean if her options had been communicated properly and if she was made aware of the poor progress of her labour and that the prospect of having a safe vaginal birth was decreasing. Subsequently, her CTG became pathological (meaning there were issues with the fetal heartbeat indicating that the baby was in significant distress), which were not properly recognised nor acted upon. A midwife did not call for obstetric input despite this being necessary at the stage that baby C’s CTG had become pathological.

Due to the pathological CTG trace indicating that baby C was in significant distress, eventually the midwives allowed the doctors into the room for assistance. A decision was made by the doctors to transfer Mrs B to theatre for an instrumental delivery, however, despite the pressing need to proceed with the instrumental delivery, the doctors instead carried out a ward round. This led to further avoidable delays in delivering baby C.

By the time that baby C was delivered via instrumental delivery she was born in extremely poor condition and had to be transferred to neonatal ICU. Tragically, she died just five days later.

Further issues occurred and were raised within statements from the Trust’s clinicians and the Serious Untoward Incident Report including inadequacies by the midwife in taking sufficient notes, ‘buddy stickers’ (stickers used to confirm the CTG was reviewed by a second person) not being used despite being available, meaning that baby C’s heartrate was not being sufficiently monitored and a communication breakdown between the obstetric and midwifery team members leading to behaviours that contributed to the delay in the decision to deliver baby C.

An inquest into baby C’s death occurred in 2021 which determined that multiple factors contributed to her death, including numerous delays in care and delivery, a lack of earlier obstetric involvement and the midwife not seeking a fresh eyes review of the CTG (which did not take place until baby C’s CTG was pathological).

Mrs and Mr B both suffered PTSD due to the loss of their daughter.

During the course of the couple’s civil legal claim the Trust accepted that the midwifery team should have sought earlier obstetric input and that, subsequently, the obstetric team should have delivered baby C within a shorter timeframe; ultimately baby C should have been delivered sooner. However, the Trust denied that staff actions had caused injury to baby C or to anyone else.