We had to fight a year and a half to have an inquest into Sofia’s death. It was difficult at times to keep our strength up. Friends questioned if it was in our best interests to keep appealing with the coroner and I’m positive it affected our psychological recovery, not being able to at least close this door. In the end, I didn’t want Sofia to only be a piece of paper for the coroner to move from his ‘in’ to his ‘out’ tray as quickly as possible.
We entered the Coroner’s Court not knowing what to expect from the coroner – would he just go through the motions as quickly as possible to finally get us out of his hair or actually do his job properly? Thankfully he did his job even more than properly, giving us a verdict that was so harsh for the hospital that our barrister had previously warned us there was no hope of getting it. Our uphill battle was worth it.
I hope this verdict makes it easier for others in the future who also have to fight to be heard.
Verdict of Coroner Dr Andrew Scott-Reid at the Poplar Coroner’s Court.
Coroner sitting at the Inquest on 9 December 2009 in which he has assumed jurisdiction.
Sofia was born on 11 February 2008 on the Labour Suite in Homerton. She was born alive, she was not stillborn. Following her birth she was cared for by the Paediatricians where she survived for three days before dying on 14 February 2008. The cause of death is Hypoxic Ischemic Encephalopathy Grade 3 and on balance this was due to intrapartum hypoxia in the second stage of labour. It is not for the Coroner to consider criminal or civil liability as this is a fact finding mission into the cause and circumstances of death.
In relation to the circumstances, he notes that Mrs Willicombe was admitted to hospital in labour with Sofia being 12 days overdue namely at 40 weeks plus 12. A sweep was performed which failed to induce labour and therefore Mrs Willicombe was admitted for the induction of labour.
Mrs Willicombe was assessed by the Specialist Trainee on the ward round and in accordance with the protocols 50 micrograms of Misoprostol was given and there was a prompt response. A review was to take place four hours later, at approximately 1400 hours. A further dose of Misoprostol was given at about 1400 hours and there is no criticism of this second dose. This is a matter of clinical judgment and in accordance with the hospital’s protocols. At this time Mrs Willicombe was monitored and there is no cause for concern and there was some reassuring features on the CTG.
The coroner noted an absence of monitoring between 1600 and 1830 hours. Mrs Willicombe was to be reviewed again but approximately half an hour before that review she was seen at 1830 hours and it was clear, following a vaginal examination, that the labour was progressing and that the cervix had dilated and therefore the decision was made to transfer Mrs Willicombe to the labour suite.
The labour suite rooms were occupied and the only room available was the mother’s suite and the midwife was asked to bring Mrs Willicombe to this at about 1835/1845 on 11 February. There was a handover to the midwife who was assigned to manage the second stage of the labour.
The midwife from Turpin ward was asked to perform a vaginal examination while the room was being prepared. The midwife confirmed that the cervix was nearly fully dilated and effaced with Mrs Willicombe well on the way. From experience it was expected that delivery would be within an hour and if not there would then be a further escalation in treatment. Thereafter between 1845 hours and 2015 hours Mrs Willicombe was under the care of the midwife in the mother’s suite.
He heard conflicting evidence and accounts of the factual situation in the second stage between 1845 and 2015. There are retrospective notes and he has heard direct oral evidence from the sister, the midwife from Turpin ward and the midwife from the mother’s suite. He preferred the evidence of the other witnesses and records which are contemporaneous. He did not find the witness evidence of the midwife from the mother’s suite to be reliable and therefore he has treated her evidence with a degree of caution.
Accepting the other evidence, he is satisfied, on the balance of probability, that during the second stage of labour there was an unacceptable level of monitoring of the fetal wellbeing. From the evidence that we can reliably obtain it satisfies him that the Trust’s own guidelines were not followed or complied with and this was sufficiently deficient. Whilst there is always risk, the monitoring is geared to identify the risk and allow the obstetricians to act to prevent adverse outcomes. Although there are technical issues and differing bodies of opinion, both in relation to obstetric and midwifery care, he finds that on the balance of probabilities the intrapartum care on the second stage of labour was particularly ineffective and lacking basic midwifery care, and putting all the evidence together at the key time this monitoring was grossly lacking. It also follows this grossly lacking care was causative of Sofia’s death. This was on the basis that at the time she was not properly monitored.
His primary conclusion is therefore she died of natural causes but he has said the test of neglect is made out in that there is a gross lack of basic care and therefore he concludes that Sofia died of natural causes to which neglect in the intrapartum care contributed.
The Coroner thereafter thanked all the witnesses concluded the Inquest and passed on his sincere condolences to the family and confirmed his sympathy was with them and hoping that this Public Enquiry would assist them.