A Suffolk coroner will write to the country’s top doctor following the two day inquest of Framlingham baby who died just moments after she was born.
Peter Dean, coroner for Suffolk, said baby Bonnie May Strachan’s ‘immediate prospects for survival’ would have been improved if a more experienced doctor had been there.
He spoke out at the end of a two day inquest into Bonnie‘s death at Ipswich Hospital, Suffolk, on January 24 this year, while being delivered naturally in a breech position.
The inquest heard how a ‘jovial atmosphere’ turned to ‘mad panic’ as junior staff struggled to deliver the baby who came out legs first.
The rest of her body was ‘left hanging’ for up to ten minutes before her arms and head were released, the inquest heard.
The child died within half an hour from asphyxia after being deprived of oxygen.
On Wednesday Bonnie’s parents called for new laws to ensure that consultants were present during all natural, breech births.
Mum Emma Strachan, 29, said: “Nothing can turn back the clock for us now but we can only hope that lessons are learned to prevent any future, avoidable baby deaths.
“Following today’s conclusions were are encouraged to hear that the issues will be raised with the chief medical officer in the hope that this will influence natural change.”
Mrs Strachan, who has a two year old son called Percy, added: “Our baby girl was taken from us and Percy’s little sister was taken from him.
“The whole situation has affected us physically, emotionally and socially.
“We feel like our world has been turned upside down and are still trying to find our feet again.
“Bonnie and I share our birthday and we just know how we will feel each time this date comes around.”
Yesterday Rohit Sharma, the hospital’s clinical director, admitted that Bonnie, would have been given a greater chance of survival had a more experienced member of staff been present.
Mr Sharma said: “The likelihood is that the resuscitation would have been successful.
“If she was delivered by 7.30 then she would have been born alive.”
Mr Sharma revealed that none of the staff present at the birth had been trained in breech births from a squatting position, which Mrs Strachan was in, and he said the family should have been made aware of this.
The inquest heard that registrar Bethany Revell was present during the delivery but had only ever attended two breech, vaginal births previously.
She had spoken to on-call consultant Andrew Leather three times before the birth but Mr Leather did not attend.
Mr Leather admitted he should have been present at the birth and claimed he was ‘misled’ by Ms Revell.
He said: “I do apologise to Emma, James and the rest of the family.
“At the time I was under the impression that the registrar was confident.
“Retrospectively I made an error of judgement and I’ve reflected on this and in the future I will attend regardless of who is present. I was misled by my telephone conversation.”
Ms Revell denied not asking Mr Leather to attend but admitted she should have been more forceful in asking the consultant to attend the birth.
Recording a narrative verdict, coroner Peter Dean said: “Bonnie died from complications following the final phase of a breech delivery.
“The presence of a consultant would have lead to an earlier delivery so immediate prospects for survival for Bonnie would have been improved but whether the ultimate outcome would have been successful cannot be determined from the evidence.”
Less than one per cent of babies born in Ipswich Hospital are natural births in the breech position and hospital guidelines advised that a consultant should be present.
Speaking after the inquest, Nick Hulme, Chief Executive of the Ipswich Hospital NHS Trust said: “We are extremely sorry baby Bonnie died and offer sincere condolences to Bonnie’s family at this awful time.
“We always work hard to learn lessons from events such as this and have made changes to our practices to improve the services we offer to all patients.
“Mothers receiving all aspects of maternity care can be reassured that the hospital’s teams will deliver high quality, safe and attentive care.”
The hospital declined to comment whether any staff faced any disciplinary action or have been given any additional training.