Royal Free London NHS Foundation Trust

3. Miss R complains the Trust failed to resuscitate her newborn son, Baby R, in June 2021.

4. Miss R says her son’s death was avoidable and he may still be here if the Trust had resuscitated him. She told us about the huge impact this has had on her. Miss R is having counselling to help with her grief and the distress these events caused.

5. Miss R would like the Trust to admit its failings and make service improvements to make this does not happen to others.

6. Baby R was born in early June 2021 at the Trust.

7. Immediately after birth, Baby R was extremely unwell. The Trust found Baby R had complications, including a brain injury and there was blood in the amniotic fluid (the liquid that surrounds and cushions the baby in the womb). Baby R was not breathing and had a low heart rate.

8. After birth, Baby R was transferred to the neonatal team for resuscitation. The Trust attempted resuscitation using differing techniques, including inflation breaths and inserting a tube into Baby R’s windpipe to help him breathe.

9. A scan of Baby R’s brain done at two days of age reported an acute hypoxic ischaemic insult, a brain injury caused by lack of oxygen to the brain.

10. Baby R stayed in a critical condition until he sadly died a few days later.

11. Miss R is concerned the Trust failed to follow guidelines when it made attempts to resuscitate her son. She thinks the tube to help him breathe was not correctly inserted and the Trust failed to recognise its mistake.

12. Miss R decided to take a legal route based on the obstetrics (maternity) care she had before Baby R was born. The Trust knows about her decision to take legal action. Miss R told us the legal claim is ongoing.

14. Miss R is using a legal route for her concerns about the maternity care the Trust gave her before Baby R’s birth. We have carefully considered if we should look at her concern about the way it resuscitated Baby R.

15. We have decided not to investigate further at this stage. This is because we would need to consider a period of care that is closely linked to what is being considered as part of ongoing legal proceedings.

16. We are aware there may be overlap with this part of the complaint and the legal case. Miss R told us she would like the Trust to admit its failings. It is possible the legal process may comment on the delivery of Baby R and if it does so, Miss R may achieve the service improvements she wants the Trust to make.

17. Our decision is to wait for the outcome of legal proceedings before we consider things further.

18. Once Miss R has completed legal action, she can come back to us with any remaining concerns that she would like us to look at. If she comes back to us, she should avoid any delay and contact us within one month of legal action completing. We would need to reconsider the time limit set for us by law that says a person should bring their complaint to us within 12 months of the date they knew they had reason to complain. There has to be good reason for us to put this to one side.

19. We thank Miss R for bringing her complaint to us and recognise how important this is to her.

1. We have carefully considered Miss R’s complaint about Royal Free London NHS Foundation Trust (the Trust). Miss R is already exploring legal action for part of her concerns about the Trust’s clinical care. We have decided not to look at the other issues Miss R has brought to us because the ongoing legal action may limit the work we can do on this. We think it is important for legal action to complete before we look any further into the concerns Miss R has brought to us.

2. We offer our deepest condolences to Miss R. We are very sorry to hear about the sad circumstances of her case. We recognise that these events continue to cause her much grief.