An inquest into the death of Cassius Knight was opened today by Assistant Coroner Dr Peter Straker at North London’s Coroner’s Court, Barnet. CL Medilaw and Nia Frobisher of 7BR are representing Ms Knight and Mr Ullens De Schooten at the Inquest.
Baby Cassius was the second child of Adele Knight and Vincent Ullens De Schooten. He was born at home; following a waterbirth overseen by two community homebirth midwives of North Middlesex University Hospital NHS Trust; now part of the Royal Free London NHS Foundation Trust.
There were clinical signs during Adele’s antenatal care that Cassius was a large baby and therefore at an increased risk of complications, such as shoulder dystocia, arising during delivery, which did sadly occur. It is alleged that there were a series of failings during Adele’s antenatal care which resulted in Adele continuing her plan for a home water birth.
The Hypoxic Ischaemic Insult Suffered by Cassius
Adele laboured at home, in a birthing pool, and sadly Cassius suffered a severe hypoxic ischaemic insult during his birth; as a result of further alleged serious failings which led to a significant delay in Cassius being delivered.
Following an investigation by Healthcare Safety Investigation Branch (HSIB – now the Maternity & Newborn Safety Investigations); a number of concerns were identified; including but not limited to a failure to refer Adele to a Consultant Obstetrician during her antenatal care so that the increased risks of having a large baby could be properly discussed with her and an appropriate birth plan then made. HSIB also found that foetal heart rate monitoring during labour was not properly performed by the two community midwives during labour and that there was a failure to consider transfer to hospital when Cassius’s well-being could not be confirmed.
Tragically, and crucially, HSIB considered that the community midwives did not recognise the obstetric emergency of shoulder dystocia (when the baby’s head delivers but the baby’s body does not follow with the same or next contraction); so there was a delay in assisting Adele to deliver Cassius. Cassius’s head remained submerged under water for a significant amount of time, during which he started suffering a hypoxic ischaemic insult (being deprived of oxygen) before Adele was assisted out of the birthing pool to aid Cassius’s birth.
It is believed that this hypoxic ischaemic insult, sustained due to prolonged oxygen deprivation at a critical stage of delivery, ultimately led to Cassius’s death. The extent and timing of the hypoxic ischaemic insult will be a key focus during the Inquest, as the Coroner examines the sequence of events that unfolded and the impact of clinical decision-making during Adele’s labour.
The Long Wait for Answers
The family have waited over three years for answers as to how Cassius died and have been subjected to continually re-living these tragic events.
During the course of the Inquest, Assistant Coroner Dr Peter Straker will hear evidence from the midwives and medical staff involved in Adele and Cassius’s care to determine how Cassius, an otherwise healthy and full-term baby, died under their care. Sadly, the family will never have the opportunity to hear from all the key individuals involved in Adele and Cassius’s care; as a Consultant Midwife involved has since moved abroad and has refused to assist the Coroner or the family at the Inquest; leaving the family in the awful position of not having answers that they deserve.
CL Medilaw Comments
Emily Markey, Associate at CL Medilaw, acting for Adele Knight and Vincent Ullens De Schooten commented that:
“Whilst there is evidence that there was an increased risk of complications arising during labour and delivery; it is alleged that these were not properly communicated to Adele; which led to Adele continuing to opt and plan for a home water birth, when neither were appropriate. However, not only was Adele failed during her antenatal care, but there is evidence of a lack of basic maternity care being provided during her labour and delivery of Cassius; care which if had been provided would likely have meant the family would not be here today; as Cassius would have survived. Adele and Vincent have found themselves in every parent’s worst nightmare, and live every day with the pain of Cassius’s loss; but also the heartbreaking knowledge that his death could have been avoided.
It is hoped that the Inquest will provide them with some answers and, in turn, accountability from the Trust for what went so badly wrong. We are pleased that the Coroner is holding a full and open hearing to seek justice for Cassius. At CL Medilaw we represent many parents and families that have lost babies, or whose babies have been catastrophically harmed, at NHS Trusts across the country and we fully support the calls for a wholesale national review of NHS maternity services.
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