Call for review of weekend staffing at maternity unit after death of newborn

A Fatal Accident Inquiry (FAI) has told a health board to review its weekend and evening staff following the death of a newborn baby in 2018.

Freya Murphy was born on July 21 2018 at 9.31am in Queen Elizabeth University Hospital (QUEH) in Glasgow and died there on July 28, aged seven days and 12 hours old.

The cause of death was given as global ischemic brain injury associated with acute chorioamnionitis.

An inquiry was held into the death where Freya’s parents questioned why the UK is not screening pregnant mothers for Group B strep, and they raised concerns about “failings in her care” at the QEUH.

First-time mother Karen Murphy and her husband, Martin Murphy, said they have been “left devastated by failings in her care” and “missed a lifetime of memories with our precious daughter”, while their other children “suffer daily without their big sister”.

Sheriff Barry Divers said that there were “no defects in any system of working which contributed to Freya’s death” and said the death “could not realistically have been avoided”.

‘Hospital able to cope better with demand on weekday’

He, however, found a “clear impression from the evidence” that if Freya’s difficult birth had occurred on a Monday rather than a Saturday, the hospital’s “inability to open a second theatre would have been one less issue to worry about”.

“It does seem to me on the basis of the evidence I heard, that if an emergency of this type arises, with two patients both of whom need to be in theatre at the same time, then QEUH is far better able to cope with that demand during a weekday than at the weekend,” Sheriff Divers said in his determination.

“As such emergencies can arise at any time, it seems to me that such a situation might amount to a defect in the system of work.”

The sheriff also made a recommendation in relation to UK policy on screening for Group B Streptococcus (“GBS”).

What happened to Freya?

Mrs Murphy, then aged 32 and a first-time mother, was deemed to be a “low-risk” pregnancy, and induction was planned for July 20 2018, however, she requested it be pushed back by three days, according to a statement of agreed evidence read to the court.

Fiscal depute Amanda Allan told the court that on July 19, Freya’s heartbeat was recorded as 150 beats per minute (bpm), and Mrs Murphy, a teacher from Cambuslang, began contractions later that day.

The following evening, Mrs Murphy arrived at the QEUH with the foetal heartbeat noted as 144bpm and she was transferred to the labour unit at about 10.20pm. At 6.30am on July 21, she was advised to start pushing, the inquiry heard.

At about 7.20am, a midwife noted that Mrs Murphy’s pulse was elevated, and informed Dr Felicity Watson, who had carried out a vaginal examination and advised Mrs Murphy that she could have a “rest from pushing for an hour”, which she declined to do, Ms Allan told the court.

Midwife Helen Kidd reported at 8.45am that a CTG (cardiotocograph) was showing signs of “deceleration”, however, Dr Amy Sinclair and Dr Marieanne Ledingham left to attend another woman, Patient A, the court heard.

At the time, 12 women were on the ward, including seven in labour. Dr Ledingham returned to review Mrs Murphy and noted “deceleration”, however, Dr Sinclair advised her that Patient A needed surgical delivery.

The court heard that Dr Sinclair and Ms Kidd delivered baby Freya at 9.30am “covered in copious thick meconium”.

Ms Allan said: “Freya was noted to be born in poor condition, she required resuscitation and CPR continued for 17 minutes.”

Freya was then transferred to neonatal ICU and was suspected to have suffered a brain injury, the inquiry heard.

Ms Allan added: “It was agreed that continuing intensive care treatment was not in Freya’s best interests and she was unlikely to survive.”

Freya died just before 10pm on July 28, aged a week old, and her cause of death was global hypoxic ischaemic brain injury associated with acute chorioamnionitis, following a post-mortem examination.

A significant clinical incident investigation review was carried out in 2019 with six recommendations, and an external review was commissioned by Dr Michael Munro, a neonatal specialist who wrote in a report that “amnionitis caused by Group B strep remains the most likely cause of Freya’s brain injury as there appears to be nothing else to cause it”, and noted that after birth, “care was delivered to (a) high standard”, the court heard.

Giving evidence by videolink, Dr Munro said: “The trajectory of the decline is really impossible to be certain of, there are no studies I’m aware of, of the specific circumstances Freya found herself in.

“The process of that starting and the baby dying can be just less than 30 minutes.”

Dr Munro said he believed Group B strep – an infection passed from the mother’s body to the baby via amniotic fluid – was “the most likely cause as there’s nothing else from the notes I’ve seen to explain what happened”.

He said: “It can cause stillbirth, therefore, what we are dealing with here is stillbirth just before Freya’s heart tragically stopped.”

He agreed that earlier delivery would have helped, but added: “I don’t think it’s possible to say, ‘had Freya been delivered at this time point she would have avoided brain injury or survived’.”

Dr Munro told the court the mortality rate (of Group B strep) is “round about 5%, it’s a minority of babies who succumb” and Freya was “close to being recorded as (a) stillbirth” as her heartrate was so slow.

He added: “A lot of women carry Group B strep, around a third – it singles out a very small number of babies, either causing a stillbirth or a baby to be born in very poor condition.”

Dr Munro said screening for Group B strep has been carried out in America since 2002, and 15,000 babies born in Scotland in 2023 would have been potentially affected by the infection.

He said the “risk of exposing lots of babies to antibiotics they don’t need” was a major consideration for medics, but added: “I would like universal screening. One of the most advanced healthcare systems in the world is doing it and you have to question why the UK is not.”

‘Tragic death left mark on doctors and midwives’

The determination said: “It was clear on the evidence that all those clinicians (doctors and midwives) who spoke to their involvement with Freya, were motivated in their actions by doing what they thought was best for Freya and Mrs Murphy.

“It was obvious during their evidence that Freya’s tragic death has left a mark upon each of them in different ways which will last for the rest of their professional careers and beyond.

“For the reasons I have explained, I have not been able to make all the findings or recommendations which they sought.

“However, I hope that the entirety of this FAI process, including the preparation for the evidential hearing, the evidence which was led, the submissions made and this determination, has at least addressed the questions which they have about what happened.

“It was suggested that the adoption of routine screening for GBS would be a suitable tribute for Freya. I understand why that submission was made.

“However, if I might respectfully say, I do not consider that would be accurate, even if it were to happen.

“The real tribute to Freya is the obvious love carried for Freya by her mother and father, which love has no doubt been passed on to Freya’s siblings.”

Health board apology

Dr Claire Harrow, deputy medical director for acute services at NHS Greater Glasgow and Clyde said: “We would like to extend our sincerest condolences to the family of Freya Murphy, and once again to apologise for the distress they have experienced.

“The care Freya received fell below the standards expected and for this, we are very sorry.

“We have received the findings from the FAI. The recommendation for NHSGGC on staffing has already been implemented.

“In line with the recommendation on Group B Streptococcus, we plan to make a formal approach to United Kingdom National Screening Committee.”