Inquest into the death of Mabel Williams at Great Western Hospital leads to a finding of Neglect due to gross failings in maternity care.
A coroner has ruled that neglect by an NHS Trust contributed to the death of a 6-day old baby following failures to warn of risk of uterine rupture and failures to identify fetal distress at birth.
The inquest into the death of 6-day old Mabel Williams, has found there were missed opportunities to avoid the tragic outcome for Mabel with the Coroner concluding that Neglect contributed to her death.
Mabel, the first baby of Rebecca and Tom Williams, was born in a poor condition at Great Western Hospital on 4 September 2023, following a period of poor maternity care provided by midwives and clinicians employed by the Trust. Mabel died on 10 September 2023 following a Hypoxic-Ischaemic Encephalopathy (HIE) insult at birth following an undiagnosed uterine rupture.
Rebecca had previously had 2 vaginal births and a caesarean section. Rebecca was advised that her pregnancy with Mabel was low risk, and she therefore opted for a VBAC (Vaginal Birth After Caesarean) delivery.
During the Inquest, Assistant Coroner Robert Sowersby heard evidence from those involved in Rebecca and Mabel’s care, both antenatally and during Rebecca’s labour as well as evidence from an expert midwife, instructed by the Coroner who was extremely critical of the standard of midwifery care.
Coroner Identifies Failings in Care
The Coroner identified multiple failings in the care provided to Rebecca and Mabel which led to Mabel’s subsequent brain injury and death. The evidence heard at the Inquest explored whether Rebecca was fully informed about the risks of a VBAC delivery finding that despite being at an increased risk of uterine rupture, Rebecca was not appropriately counselled about the risks – specifically that this was an event which could prove fatal to Mabel. It was Rebecca’s evidence that had she been appropriately counselled she would have requested a caesarean section.
The Coroner also found that there were missed opportunities by the midwifery staff to recognise the severity of Rebecca’s clinical condition during labour, to pick up signs that Mabel was in distress and being deprived of oxygen, and to obtain appropriate clinical input which would have expedited Mabel’s birth and avoided the subsequent tragic outcome.
The failings identified in the maternity care at Great Western Hospital include:-:
- Gross failings to provide basic care including failures to escalate care for an obstetric review following blood loss, failures to interpret and escalate a pathological CTG and failures to identify the cause of uterine pain and palpate the abdomen at any time.
- Failings where care fell below the expected standard of a competent midwife including a failure to perform a vaginal examination, reduce/stop oxytocin (a hormone that stimulates contractions of the uterus) when CTG concerns were identified, failures to interpret the CTG correctly and failures in managing a fetal bradycardia (slow heart rate).
The Coroner commented on the following further failures in care:-
- Failing to take informed consent for a VBAC delivery by not explaining the risk and implications of uterine rupture.
- Failing to take informed consent for the commencement of oxytocin;
- The failure to inform Mabel’s parents of what was going on and involve them in decision making.
Coroner’s Comments
“Mabel Williams died because numerous indicators of her own distress, and of the increasing severity of her mother’s clinical condition, went unrecognised by the midwifery staff involved in her care or were not conveyed to the clinical team in time to expedite her birth safely”. Assistant Coroner Robert Sowersby.
The Coroner concluded that Mabel’s death was contributed to by Neglect and has asked the Trust to provide him with further evidence to consider whether it is appropriate to write a prevention of future deaths report (a document issued by a Coroner, which highlights concerns about circumstances that could lead to future deaths and recommends actions to prevent them).
CL Medilaw Comments
Amy Milner, Senior Associate at CL Medilaw, who is representing Rebecca and Tom Williams, commented:
“This is an extremely tragic case where the Coroner identified so many failings in respect of the care that both Rebecca and Mabel received, but for which Mabel would have survived. Whilst the family are grateful to the Coroner for his thorough investigation, they found it extremely difficult and traumatic hearing from those involved in Mabel’s care, and hearing first-hand the catalogue of failures and missed opportunities that led to their otherwise healthy baby daughter, suffering a severe brain injury and ultimately succumbing to her injuries at just 6 days age.
“We hope that having heard the evidence and the Coroner’s concerns, that the Trust will take steps to make changes to practices and policies, to ensure expectant mothers trialling a VBAC are fully informed of the risks associated with the same, as well as to provide midwives with appropriate training of when to detect concerns with fetal heart rates and when it is appropriate to escalate matters and obtain clinical input.”
CL Medilaw represents families across the UK whose children have died or suffered catastrophic harm, such as HIE and cerebral palsy, due to maternity care failures, including those involving VBAC risk factors and complications during delivery.
The family is also being represented by Emily Raynor of Old Square Chambers.
For all enquiries, please contact Amy Milner by email at CL Medilaw or by telephone on 0345 2410 154.
