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Failings on labour ward contributed to baby’s death, says coroner’s report (5 May 2015)

Date: 05/05/2015
Duncan Lewis, Clinical Negligence Solicitors, Failings on labour ward contributed to baby’s death, says coroner’s report

A coroner’s report to Barking, Havering and Redbridge NHS Trust has highlighted a series of failings on a labour ward, where a baby was born after a delayed Caesarean and subsequently died.

The Evening Standard reports that Iana-Liza Chervonenko was born at 2.30am on 8 March 2014 at Queen’s Hospital in Romford with no heart rate or spontaneous respiration. She died 24 hours later.

Queen’s Hospital maternity unit is one of the busiest in the county and on the night Iana-Liza was due to be delivered, her mother’s emergency Caesarean section was delayed for nearly two hours because of pressure on staff.

A midwife at the maternity unit was so alarmed by the delay that she took a printout of the baby’s deteriorating heart rate to a surgeon operating on another patient and showed it to him.

However, Iana-Liza’s delivery was wrongly downgraded to second-level priority and another patient was operated on before the baby was delivered.

Iana-Liza’s father Serhiy Chervonenko from Ilford said that his wife was so distressed by their loss that she has left the UK.

The case was highlighted in a report by Walthamstow coroner Nadia Persaud on how to prevent deaths in the future. She has ordered Queen’s Hospital to take immediate action to increase staff numbers on the maternity ward.

Queen’s Hospital in Romford has been in special measures since December 2013 – the Care Quality Commission warned in 2011 that its maternity services were dangerously understaffed.

The hospital handles around 9,000 births every year.

In her report, coroner Nadia Persaud writes:

“I am concerned about the level of medical cover on the labour ward. The doctors were under severe pressure due to the amount of work.”

Returning a narrative verdict on Iana-Liza’s death, Ms Persaud said that her mother – who has not been named – was one week overdue when she arrived at Queen’s Hospital maternity unit.

Ms Persaud said that “poor communication and poor decision-making” had been responsible for the delay in delivering Iana-Liza by C-section – and added that the baby’s death was contributed to by neglect.

Associate Medical Director at Barking, Havering and Redbridge NHS Trust, Magda Smith said:

“We would again like to apologise to Iana-Liza’s family for her tragic death.

“We already have one of the highest levels of medical staffing in the country on our labour ward.

“We are now recruiting more obstetric consultants to make us among the first in the UK to have consultants present in our maternity department twenty-four hours a day.”

Ms Smith added that further training had been provided to staff on the maternity wards, with system to alert the labour ward when an obstetric operating theatre was available and ready for use.

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