Ted Stewart

On 19 December 2024 I commenced an investigation into the death of Ted Oliver STEWART, aged 8 days. The investigation concluded at the end of the inquest on 30 June 2026.

The conclusion of the inquest was a narrative conclusion as follows; On 11 December 2024, whilst Ted Oliver Stewart was still in utero, his mother, who was 38 weeks and 2 days pregnant, attended the Jessop Wing with abdominal pain and vaginal bleeding.

Clinical assessment raised the possibility that Ted was in an oblique lie rather than a head-down presentation. This should have prompted an ultrasound scan to confirm presentation and as Ted was lying obliquely admission to hospital for ongoing management.

Ted’s mother was assessed by a junior doctor early in her obstetric training and she did not appreciate the significance of an oblique lie.

There was no national or local guidance  available to assist her. She consulted with a senior colleague but the possible oblique lie was not effectively conveyed, understood or acted upon and Ted’s mother was discharged home.

Shortly after returning home, Ted’s mother went into active labour and Ted began to be born feet first. Paramedics attended but were unable to complete the delivery and transported Ted and his mother to the Jessop Wing. Ted was born in the ambulance whilst on his way to hospital. He was not breathing and required neonatal life support.

Ted died on the 19 December 2024 at the Jessop Wing Sheffield as a result of a severe hypoxic and ischemic brain injury caused by head entrapment during the breech delivery. Had his mother been admitted to hospital, she would have had the opportunity either to undergo an emergency caesarean section or if vaginal delivery was unavoidable, to deliver in a hospital setting with appropriate obstetric and neonatal support and on the balance of probabilities, Ted would not have sustained the injury from which he died.

The medical case of death was 1a   Hypoxic Ischemic Encephalopathy 1b   Term Breech Vaginal Delivery With Head Entrapment

On the 11 December Ted’s mother attended Jessop wing at 38+2 gestation with back pain and bleeding. She was examined by an ST1 and on examination noted that Ted may be at an oblique lie. This was annotated in the medical notes. The ST1 was early in their obstetrics career and did not understand the significance of this find. The ST1 searched for both national and local guidance on presentation of an oblique lie; none was found as it did not exist. The ST1  consulted with an ST7 but the oblique lie was not effectively communicated and Ted’s mother was discharged home. Ted’s mother went into labour later that day at home and assisted by paramedics Ted was delivered whilst en route to hospital. Due to head entrapment it was estimated that Ted’s umbilical cord was not perfused for approximately 15 minutes. On delivery Ted was not breathing and had no heart rate and neonatal life support was commenced. An MRI showed extensive damage to his brain and on the 19 December Ted died. Ted’s mother should have been admitted to Hospital on identification of Ted’s oblique lie. Ha she been then on the balance of probabilities Ted would not have died.

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.