Source · Prevention of Future Deaths
Millie-Rae Needham
Ref: 2022-0122
Date: 25 Apr 2022
Coroner: Abigail Combes
Area: South Yorkshire (West District)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryDelayed delivery and inadequate fetal heart rate monitoring arose from a midwife being discouraged from performing an episiotomy. Concerns were also raised about insufficient patient consultation on birthing options and potentially influencing language in birth documentation.
Date
25 Apr 2022
56-day deadline
21 Jun 2022
stated in the report
Responses identified
0 of 1
Coroner's concerns
Delayed delivery and inadequate fetal heart rate monitoring arose from a midwife being discouraged from performing an episiotomy. Concerns were also raised about insufficient patient consultation on birthing options and potentially influencing language in birth documentation.
View full coroner's concerns
1. A decision was made by the midwife who had been with throughout her delivery to move to an episiotomy. Instead, the midwife that came to support encouraged further position changes leading to delay in delivery and inadequate monitoring of the foetal heart rate. Whilst the decision seek support for the episiotomy is not one which I would criticise, people should always be able to ask for help when needed, the fact that the midwife who was with was talked out of this so readily resulting in avoidable delay is concerning.
2. The decision to move from consultant to midwife led care without consultation, although not contributory to Millie-Rae's death is concerning.
3. The lack of discussion with about birthing options prior to labour and therefore the lack of engagement with the pregnant woman is concerning.
4. I have had sight of the new documentation around 'Born in Sheffield' and I am concerned by reference to 'normal birth' on the checklist. Again, this appears as though it is encouraging expectant mothers to be influenced into a natural birth when they may prefer to explore options such as caesarean section. Language is hugely important in terms of the experience individuals have when vulnerable.
5. Evidence was given about fresh eyes on continuous heart rate monitoring but there appear to be no safeguards in place for those not on continuous heart rate monitoring.
2. The decision to move from consultant to midwife led care without consultation, although not contributory to Millie-Rae's death is concerning.
3. The lack of discussion with about birthing options prior to labour and therefore the lack of engagement with the pregnant woman is concerning.
4. I have had sight of the new documentation around 'Born in Sheffield' and I am concerned by reference to 'normal birth' on the checklist. Again, this appears as though it is encouraging expectant mothers to be influenced into a natural birth when they may prefer to explore options such as caesarean section. Language is hugely important in terms of the experience individuals have when vulnerable.
5. Evidence was given about fresh eyes on continuous heart rate monitoring but there appear to be no safeguards in place for those not on continuous heart rate monitoring.
Report sections
Investigation and inquest
On 22 January 2021 I commenced an investigation into the death of Millie Rae-Needham born on 6 August 2020. The investigation concluded at the end of the inquest on 17 February 2022. The conclusion of the inquest was:- Millie-Rae Needham was born at the Jessop’s Wing of Sheffield Teaching Hospitals on 6 August 2020. As a result of clinical decisions there was a 23-minute delay in her delivery and during that time her condition was not adequately monitored. She died in the neonatal unit at the hospital on 9 August 2020. Her death was contributed to by neglect. The medical cause of death was: 1a: Hypoxic-ischaemic encephalopathy 1b: Intra-uterine hypoxia
Circumstances of the death
Millie-Rae Needham was born at the Jessop's Wing of Sheffield Teaching Hospitals on 6 August 2020. Her mother (Skinna) had been categorised as a high-risk pregnancy throughout her pregnancy as a result of a previous baby with a very low birth weight. On the last scan was switched to midwife led care rather than consultant led care with no consultation and as a result Millie-Rae was born on the midwife led unit at the Jessops. Throughout labour was given very high pain relief early in her labour journey with minimal effect. Millie-Rae's heart rate was listened to periodically using auscultation. Once it became apparent that labour was not progressing as it had been hoped the midwife determined that an episiotomy would be needed. She did not feel confident in doing this without support and so requested assistance. The midwife that then came into the room encouraged further position changes and this resulted in a 23-minute delay in Millie-Rae being born. During that time there was no adequate monitoring of her heart rate resulting in her being born in a very poor condition and dying on 9 August 2020.
Action should be taken
I would ask that your responses specifically consider the following:-
1. Engagement with families and especially expectant mothers about their preferences for birth. The real pros and cons of consultant led and midwife led care.
2. How the unit will work on culture to ensure that those who have the most knowledge are supported to lead decision making and not be talked out of that decision upon the arrival of someone more senior or more experienced.
3. Guidance for how to make safe decisions.
4. The equivalent safeguard for expectant parents and babies of fresh eyes when they are not on continuous heart rate monitoring
5. How expectant parents know exactly what to expect from a labour and what level of service they should expect. Make the NICE guidelines accessible so that parents are true partners in their care.
1. Engagement with families and especially expectant mothers about their preferences for birth. The real pros and cons of consultant led and midwife led care.
2. How the unit will work on culture to ensure that those who have the most knowledge are supported to lead decision making and not be talked out of that decision upon the arrival of someone more senior or more experienced.
3. Guidance for how to make safe decisions.
4. The equivalent safeguard for expectant parents and babies of fresh eyes when they are not on continuous heart rate monitoring
5. How expectant parents know exactly what to expect from a labour and what level of service they should expect. Make the NICE guidelines accessible so that parents are true partners in their care.
Similar PFD reports
Report details
- Reference
- 2022-0122
- Date of report
- 25 April 2022
- Coroner
- Abigail Combes
- Coroner area
- South Yorkshire (West District)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Jun 2022 (stated in the report).
Sent to
- Sheffield Teaching Hospitals NHS Foundation Trust