Framlingham parents speak of ‘utter panic’ when baby died moments after birth at Ipswich Hospital at emotional inquest

Emma and James Strachan with their son Percy

Emma and James Strachan with their son Percy - Credit: Archant

Bonnie Strachan died at Ipswich Hospital on January 24.

She was deprived of oxygen when she was delivered in an “extremely poor condition” in the breech position – meaning she was born bottom rather than head first.

Her parents, Emma and James Strachan, from Framlingham, who have a two-year-old son called Percy, had decided against a caesarean section as is common practice for breech babies in the UK.

Giving evidence at an inquest in Ipswich on Tuesday, Mrs Strachan, 29, raised concerns about the advice they were given during pregnancy and a series of mistakes in labour.

She also said the delivery had not been taken seriously enough, with one midwife joking that the hospital could “sell tickets” for the unusual vaginal breech birth procedure.


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Describing the delivery, which took place on her own birthday, Mrs Strachan said: “We feel like our world has been turned upside down while we find our feet. Our baby girl was taken from us and Percy’s little sister from him.

“We feel this has affected us physically, emotionally and sociably. James is suffering from flashbacks and he is unable to talk about what happened in the delivery room.

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“The thought of a future pregnancy, labour and birth currently petrifies us.”

She said the registrar responsible for the delivery had only delivered two breech babies previously and the latter moments of the delivery had been “panicked” and a “mad fumble”.

After emerging bottom and legs first, the family felt Bonnie was “left hanging” for several minutes before her arms and head were released.

When she was eventually delivered she was rushed to a resuscitation table but the oxygen ran out, Mrs Strachan said.

She added that staff seemed under-prepared for the delivery, for example not having the right sized forceps available.

The couple had also been told their baby was of average size but after birth it emerged she was larger than average, which is an additional risk factor.

Earlier in the delivery, Mrs Strachan said the atmosphere had been “too relaxed”, leading her to think the situation was not being treated with sufficient seriousness.

She added: “It was a jovial atmosphere. The midwife commented that everybody wanted to watch a vaginal breech delivery, saying ‘We could sell tickets’. In many ways it seemed too relaxed. Looking back, at times I felt left alone while everybody around me was relaxed and jovial.”

The inquest heard that Bonnie was born “pale and floppy” and could not be resuscitated despite doctors trying for 29 minutes.

Paediatric pathologist Zoe Mead said she found evidence of asphyxia and hypoxia associated with low oxygen levels.

She said Bonnie was larger than average and this, along with the breech position, were risk factors which could have contributed.

“Although there are risk factors it is difficult to know in this case what specifically caused the hypoxia which I thought was there,” Dr Mead added.

The couple had considered a procedure to turn the baby during pregnancy.

However, after taking advice from a consultant, they decided against this because of the risks involved and the low chances of success.

They were also concerned about the complications associated with a caesarean, particularly as Mrs Strachan had suffered previous health problems including diabetes and an appendectomy. The couple also went through a previous miscarriage.

Mrs Strachan said they were informed that, because of the established practice of delivering breech babies by caesarean, many medics were not accustomed to performing vaginal breech births but they were reassured about the risks.

“We were told that if a vaginal breech birth wasn’t progressing as expected a caesarean would be performed,” Mrs Strachan said.

“We thought that this was a good option. We do not feel we had properly been made aware of the risks of a vaginal breech delivery.”

The couple’s consultant Andrew Leather, who is an expert in breech deliveries, was phoned three times during the labour, the inquest heard. It is hospital guidelines that an experienced consultant should be present at vaginal breech deliveries.

Mr Leather told the inquest he would have been happy to attend the delivery had he been asked and was surprised his presence was not requested by the registrar Bethany Revell.

“I did not specifically ask her how many breech deliveries she had done,” he added. “She had been a registrar in our ward for five months or so and when I dealt with her she had been confident. I had no reason to question her hence when she gave me a confident answer I accepted that she was happy.”

Coroner Peter Dean questioned Mr Leather on his decision not to perform a scan on Mrs Strachan on their last meeting before the birth to ascertain the size of the baby. He said in his experience, there was no evidence to suggest that a baby’s size made any difference to the outcome of a breech delivery.

He had been happy with the couple’s decision to go for a vaginal delivery despite the breech complication and did not ask about their reasoning.

Dr Revell, who was in charge of the delivery, sobbed as she gave evidence.

She admitted she had not requested Mr Leather attend, saying: “I never said no but I never said yes.”

Dr Revell said she identified the situation as an emergency as soon as she detected a low foetal heart rate.

She added: “The baby could have been delivered sooner but whether it would have changed the outcome, I don’t know.”

Mr Leather admitted a lack of experience led to a delay in action during the birth of Bonnie, and had he been there she could have been delivered two to three minutes earlier. He could not say if this would have changed the outcome.

Mr Leather said in the future, when he received a call about a breech vaginal birth, he would simply go to the hospital.

The family has instructed medical negligence law firm Irwin Mitchell to represent them.

Dr Dean is expected to conclude the inquest on Wednesday.

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