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A Scottish judge has ruled that the deaths of three babies during childbirth could “realistically” have been avoided if maternity staff had been correctly trained.
Sheriff Principal Aisha Anwar KC said hospitals across Scotland should introduce a “trigger list” of early labour warning signs that would immediately lead to women being called in for hospital assessment.
Hospitals should also have a digital register and critical alert system for mothers who had previously had pre-term labour problems, a dedicated “red phone” in maternity units for emergency calls from ambulance crews, and improved handling of potentially difficult births.
Her 11 recommendations followed a fatal accident inquiry, a Scottish process similar to an inquest but only called in particular cases, into the deaths of three babies in two hospitals in Lanarkshire in 2019 and 2021.
The circumstances of each death were different except that in all three, warning signs of a pre-term or difficult birth were not immediately acted on by hospital staff working for NHS Greater Glasgow and Clyde.
The first involved Leo Lamont, who died two hours after birth in February 2019 after being born very prematurely. His mother had complained to the hospital of severe back pains but was told to take paracetamol; soon afterwards she gave birth in the bathroom at home.
Three weeks later, Ellie McCormick died from oxygen starvation five hours after birth at a different hospital. Her mother told the ward by phone she was experiencing contractions; she was advised to take painkillers and call back if her waters broke or she was not coping.
Three hours later she called, and was admitted to hospital for an emergency caesarean when staff found Ellie had a slow heart rate. The baby did not survive.
In the third case, in July 2021, Mira-Belle Bosch died 12 hours after birth owing to brain injuries from lack of oxygen during birth. Her mother had reported contractions and that her waters had broken three days earlier.
She said she was comfortable at home but two days later, her baby’s feet were presenting. Paramedics were unable to deliver the baby and it took them five attempts to reach the hospital maternity unit by phone. Mira-Belle was born in hospital but was unresponsive; her ventilator was switched off two days later.
Anwar said: “The death of a child is an unimaginable and deeply painful event in an parent’s life, one from which it is undoubtedly difficult to recover.
“The purpose of this inquiry is to understand what happened and what might be done in future to avoid such tragedy. I again offer my deepest condolences to the parents of Leo, Ellie and Mira-Belle.
“Each gave evidence with great dignity and sought to assist the inquiry notwithstanding the anguish and heartache each has suffered.”
In a statement, the McCormick family said they could not have imagined the individual and system failures the inquiry brought to light.
“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,” they said.
“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.”
