Deaths of three babies at Lanarkshire hospitals could have been avoided, inquiry finds

The deaths of three newborn babies could have been avoided if reasonable precautions had been taken, a fatal accident inquiry has concluded.

The inquiry was launched after the deaths of Leo Lamont, Ellie McCormick and Mira-Belle Bosch within hours of their births at two hospitals in North Lanarkshire.

Aisha Anwar KC, sheriff principal of Glasgow and Strathkelvin, issued her determination on Tuesday into the deaths.

She said “reasonable precautions” could have been taken that might “realistically” have saved each baby’s life.

In each case the baby’s mother had been in contact with a hospital in the hours before giving birth, but had been advised to stay at home rather than go in for an assessment.

The report also highlighted “defects in systems of working” in the hospitals, pointing to a lack of guidance for midwives in assessing preterm labour symptoms, and the lack of an “effective means” of flagging pregnant women’s risk on hospital systems.

It also flagged issues with the interpretation of guidance around when to induce labour after a woman’s waters have broken.

Leo

Leo was two hours old when he died at University Hospital Monklands on February 15, 2019.

His mother Nadine Rooney had a history of preterm delivery and had reported episodes of bleeding during her pregnancy.

She was 27 weeks into her pregnancy when she called the Princess Royal Maternity Hospital in Glasgow at 3.17am on February 15 complaining of “agony” in her back.

A midwife advised her to take painkillers and to call back if the pain did not improve, and she gave birth to Leo on her bathroom floor just before 5am.

Mother and child were rushed to University Hospital Monklands but Leo was pronounced dead at 7.10am having suffered from a shortage of oxygen during and shortly after labour.

Ms Anwar found Leo’s death might realistically have been avoided if his mum had been advised to attend the maternity assessment unit for further assessment on February 15 and if she had acted upon that advice.

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

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

“We have received the findings from the FAI. A number of the recommendations for NHSGGC have already been implemented, including preterm guidelines and improvements to electronic record keeping. Others are in progress and should be fully implemented by early summer.”

A statement issued on behalf of Leo’s family said: “Leo’s family are grateful to Sheriff Principal Anwar for the sensitive manner in which she conducted the inquiry and for her careful consideration of the evidence.

“The family hope that lessons are leant from the tragedy of the deaths of Leo, Ellie and Mira-Belle, for the safety of other families in the future.

“Leo’s family have been through an extraordinarily difficult ordeal and would be grateful for privacy to allow them to attain closure and focus on their family.”

Ellie

Ellie’s mother Nicola had also reported episodes of bleeding during her pregnancy, but her observations had been considered normal.

She called the maternity unit at about 4.30pm on March 4, 2019, to report that she was experiencing contractions, and was advised to take painkillers and have a bath or shower, and to call back if she was “not coping”.

When she called again at about 7.30pm she was advised to go in, and her baby’s heartbeat was found to be slow so medics carried out an emergency caesarean section.

After being delivered Ellie was in “poor condition and there were no signs of life”, and she was pronounced dead at 2.20am having suffered a brain injury due to a lack of oxygen during labour.

Ms Anwar found Ellie’s death might realistically have been avoided if her mother had been advised of the need for induction at or before 40 weeks gestation when she attended for assessment on February 13 and if she had acted upon that advice; or if she had been advised to attend Wishaw General Hospital for assessment following her call to the maternity triage unit at 4.29pm hours on March 4, 2019 and if she had acted upon that advice.

A statement issued on behalf of Ellie’s family said: “Over six years ago, the McCormick family lost their baby daughter Ellie in what has proven to be very avoidable circumstances. The determination marks the end of what has been a very lengthy process in the pursuit of answers and accountability. The family could simply never have imagined the scale of both the individual and systems failures that came to light during the Inquiry.

“What seemed to be flaws with the electronic system of record keeping actually turned out to be a catalogue of errors with numerous opportunities to avoid the tragic outcome that followed. The determination sets out in considerable detail all of the failures that contributed to Ellie’s death.

“The family is grateful for the careful and considered analysis of the court and for the sensitive way in which the Inquiry was conducted. At no point did they feel that Ellie, Leo or Mira-Belle had been forgotten about and the family again wish to express their condolences to the other families involved.

“It was extremely difficult for the family to hear the evidence and reading the determination is bittersweet in terms of achieving some sense of closure but also learning once again how different things ought to have been.

“As the court commented at the outset, the death of any child is an extremely painful event and the family can only hope that all of the recommendations will be implemented in full and as a matter of priority. The family has an expectation that all of the Health Boards across Scotland will take the recommendations very seriously to ensure all possible lessons have been learned and that such tragic events are avoided in the future.

“The family would again ask for time to consider the lengthy determination in private and do not wish to make any further comment at this stage.”

Mira-Belle

According to the report, Mira-Belle’s mother Rozelle’s pregnancy had gone smoothly.

She called the maternity ward at Wishaw General Hospital at about 8.50pm on June 30 2021, reporting that her waters had broken and she was experiencing contractions.

She went in for an assessment but was discharged, and called the unit again at about 2.30pm on July 1 and was advised to remain at home.

About eight hours later, her partner called for an ambulance reporting that the baby was being born feet-first.

When paramedics arrived they tried phoning the maternity unit for advice, and had to call five times before they could get through.

After they attempted to deliver the baby in situ Mrs Bosch was rushed to hospital, where Mira-Belle was delivered but found to be unresponsive.

She was pronounced dead at 12.30pm on July 2, having suffered a brain injury due to a lack of oxygen.

Ms Anwar found Mira-Belle’s death might realistically have been avoided if her mother had been advised to attend Wishaw General Hospital for induction approximately 24 hours after her waters had broken and if
she had accepted that advice.

She said it might also have been avoided if she had been offered the option of admission to Wishaw General Hospital on 30 June, 2021 to await induction of labour when possible and she had chosen that option.

Recommendations

In her report Ms Anwar offered condolences to the bereaved parents, who she said had given evidence “with great dignity” during the inquiry.

“The death of a child is an unimaginable and deeply painful event in any parent’s life; one from which it is undoubtedly difficult to recover,” she said.

“What ought to have been a time of celebration for the parents and families who awaited the births of Leo, Ellie and Mira-Belle turned to one of sorrow and tragedy.”

The report makes 11 recommendations, including the drawing-up of a “trigger list” for identifying preterm labour symptoms, and the introduction of a dedicated telephone line to give ambulance service staff direct access to maternity units.

It also recommends that women are given an “approximate timeframe” in which to call back when told to see if symptoms improve after taking painkillers, as well as recommending improvements in the way information is recorded on hospital systems.

‘Sincerely regret the pain and distress these families have experienced’

Trudi Marshall, executive nurse director at NHS Lanarkshire, said: “We extend our deepest sympathies to the families of Leo Lamont, Ellie McCormick and Mira-Belle Bosch.

“We sincerely regret the pain and distress these families have experienced and we recognise their strength and bravery in sharing their experiences during the Fatal Accident Inquiry (FAI).

“We acknowledge the findings of the FAI which we will carefully consider to ensure that the lessons learned are fully acted upon.

“Following the reviews we carried out into these tragic events, we have already put in place a range of actions that align with the Sheriff Principal’s recommendations for NHS Lanarkshire and maternity units in Scotland.”

Procurator Fiscal Andy Shanks, who leads on fatalities investigations for the Crown Office and Procurator Fiscal Service, said:  “The tragic deaths of Leo, Ellie and Mira-Belle have been an overwhelming loss for their families and they have my deepest sympathy for all they have suffered. 

“I hope that these proceedings provided the families with the answers they sought, and the sheriff principal’s determination, which is extensive and detailed, helps to prevent similar deaths in the future.” 