Suffolk couple hope lessons will be learnt from tragic death of their baby
- Credit: Archant
A coroner has called for a national review of breech baby deliveries after an inquest heard a girl died at birth following a series of failings.
Bonnie Strachan died at Ipswich Hospital on January 24 after being deprived of oxygen when she was delivered in the breech position - meaning she was born feet rather than head first.
Her parents, Emma and James Strachan, from Framlingham, had decided against a caesarean section as is common practice for breech babies in the UK.
An inquest in Ipswich heard that the policy of delivering most breeches by caesarean has meant there is a lack of professionals experienced in vaginal breech deliveries.
In this case guidelines stated that a consultant who was skilled in such unusual deliveries should have been present but he failed to attend.
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Giving evidence, Mrs Strachan, 29, said: “We do not feel we had properly been made aware of the risks of a vaginal breech delivery.”
Coroner Peter Dean said he was satisfied lessons had since been learnt locally but added it was important for this experience to be shared elsewhere.
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He said he would write to the chief medical officer to emphasise the importance of having a consultant present for such high risk deliveries.
“I hope this will prevent similar tragic circumstances in future,” he added.
Dr Dean recorded a narrative conclusion, saying: “Bonnie died from complications following a prolonged final phase of a breech delivery.
“The presence of a consultant would have led to an earlier delivery and the immediate prospects for survival would have been improved.
“Whether the ultimate outcome would have been successful simply cannot be established.”
Dr Dean gave credit to the “effort and bravery” it took for Mr and Mrs Strachan to give evidence personally during the hearing.
The inquest heard consultant obstetrician Andrew Leather, who advised the couple before the birth, did not attend the delivery despite the hospital’s own guidelines.
He said that in hindsight he should have attended instead of leaving a registrar who had previously performed only two breech deliveries to take charge.
“At the time I believed the registrar was confident,” he added.
“Retrospectively I obviously made an error of judgment and in future I will always attend regardless of the experience of who is present, but I was misled by our telephone conversation.”
Registrar Bethany Revell said Mr Leather was telephoned three times during the delivery but there was confusion over whether he would attend or not.
After emerging feet first, the family felt Bonnie was “left hanging” before midwives decided to release her arms and head.
The inquest heard that with her umbilical cord compressed, a 10 minute window of opportunity in which to deliver Bonnie before foetal reserves were exhausted was missed.
Mr Leather said that had he attended it would have been realistic to deliver a breech baby five or six minutes earlier. This is likely to have meant she survived longer than the 29 minutes she did.
Speaking outside the inquest, the couple said they hoped the findings would help other parents.
Mrs Strachan added: “We hope lessons can be learned to avoid further preventable baby deaths.
“Following today’s conclusion we are encouraged to hear the issues will be raised with the chief medical officer in the hope that this influence national change.
“We are aware that the trust has made changes to its guidelines and taken action to ensure there clearer systems in place to prevent the mismanagement of breech deliveries.
“Bonnie and I share our birthday and we just don’t know how we will feel each time this date comes around.”
Their solicitor Guy Forster, from the firm Irwin Mitchell, said the couple had never been interested in a witch hunt.
“We hope this conclusion can influence policy locally but also nationally,” he added.
“The coroner’s decision to write to the chief medical officer is very significant and hopefully that will bring about a real change.”
Nick Hulme, chief executive of The Ipswich Hospital NHS Trust, said improvements had been made to services as a result of Bonnie’s death.
He added: “Mothers receiving all aspects of maternity care can be reassured that the hospital’s teams will deliver high quality, safe and attentive care.”