FAI DETERMINATION SUMMARIES

The Sheriff Principal has made 11 recommendations following the deaths, including:

• The creation of a ‘trigger list’ to identify and assess preterm (early) labour symptoms and provide guidance on when women should attend for clinical assessment

• A review of the information held in electronic records of previous preterm births

• A review of the Electronic Record Keeping Guidance issued by the Royal College of Midwives

• A system for the exchange of information upon the change of a named midwife

• The introduction of a direct telephone line to each maternity unit in Scotland solely for the use of Scottish Ambulance Service crews

• The introduction of hand held scanners to assist in the detection of breech births                 

The Sheriff Principal also noted two observations. These were:

• If a neonatal death is reported to the Scottish Fatalities Investigation Unit of the Crown Office and Procurator Fiscal Service, as soon as possible thereafter, the health board should preserve and retain a copy of the mother’s electronic records.

• Health boards should consider storing recordings of triage calls so that, if required, they can made available to serious adverse event reviews and fatal accident inquiries.
  

Background

Leo Lamont

Leo Lamont died at 0710 hours on 15 February 2019 at University Hospital, Monklands.  He was 2 hours old at the time of his death. The causes of Leo’s death were (a) perinatal (intrapartum and postpartum) hypoxia (b) placental abruption and (c) extreme prematurity.  He suffered from a deficiency of oxygen during and shortly after labour.

Leo’s mother, Nadine Rooney, has a history of preterm delivery and had previously reported bleeding. At 0317 hours on 15 February, at approximately 27 weeks, her partner contacted the Princess Royal Maternity Hospital in Glasgow to report that she was experiencing back pain. She was advised to take painkillers and to call back if the pain did not improve. Later that morning, at 0458 hours, her partner contacted the ambulance service to report that Ms Rooney had given birth on their bathroom floor.

An ambulance crew arrived at 0517 hours and Leo was found to be cyanosed (blue in colour) and intermittently gasping for breath. Both Leo and Ms Rooney were taken to University Hospital, Monklands, where Leo was later pronounced dead.

Ellie McCormick

Ellie McCormick died at 0220 hours on 5 March 2019 at Wishaw General Hospital, Lanarkshire.  She was 5 hours old at the time of her death. The cause of Ellie’s death was hypoxic ischaemic encephalopathy due to intrapartum hypoxia. She suffered a brain injury caused by a lack of oxygen during labour.  

This was Ellie’s mother, Nicola McCormick’s, first pregnancy and she had reported periods of bleeding and reduced fetal movement, but on examination her observations were considered to be within normal limits. At around 1629 hours on 4 March, she called the maternity triage unit at Wishaw General Hospital to report that she was experiencing contractions. She was advised to take painkillers and call back if she was ‘not coping’, her waters had broken or she had any concerns. She called back at 1932 hours and was advised to attend at the hospital. When admitted, the fetal heart rate was recorded as below normal and the decision was taken to perform an emergency caesarean section.

Following the birth, Ellie was in a poor condition and taken to the neonatal team. She had been deprived of oxygen for too long and was unable to survive despite full resuscitation.

Mira-Belle Bosch

Mira-Belle Bosch died at 1230 hours on 2 July 2021 at Wishaw General Hospital.  She was 12 hours and 1 minute old at the time of her death. The causes of Mira-Belle’s death were (a) hypoxic ischaemic encephalopathy due to (b) breech home delivery with fetal head entrapment. She suffered a brain injury caused by a lack of oxygen during labour.

This was Mire-Belle’s mother, Rozelle Bosch’s, first pregnancy. During her pregnancy, she was referred for a fetal growth scan and measurements were found to be normal. There were no other concerns. At around 2052 hours on 30 June, Mrs Bosch contacted maternity triage at Wishaw General Hospital to report that her waters had broken and she was experiencing contractions. She was advised to attend for an assessment and was later discharged with advice. At around 1429 on 1 July, she again called maternity triage to report contractions. At that time she reported that she was comfortable at home and had no concerns and was advised to remain at home.

At 2248 hours on 1 July, her partner placed a call to the ambulance service and reported that the baby’s feet were presenting. A crew arrived at 2259 hours and shortly after, the paramedics made calls requesting further assistance. They also attempted to contact the maternity unit at Wishaw General five times before the call was eventually answered. After receiving advice and conducting failed attempts to assist delivery, the decision was taken to take Mrs Bosch and Mira-Belle to the hospital, where Mira-Belle was delivered and found to be unresponsive.

Mira-Belle was ventilated, but following discussions with her parents, it was agreed on 2 July that life support should be withdrawn. 

Reasonable precautions

Leo Lamont

Leo’s death might realistically have been avoided if his mother had been advised to attend the maternity assessment unit at the Princess Royal Maternity Hospital, Glasgow, for further assessment on 15 February 2019 and if she had acted upon that advice.

Ellie McCormick

Ellie’s death might realistically have been avoided if Ellie’s mother had been advised of the need for induction at or before 40 weeks gestation when she attended for assessment on 13 February 2019 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 1629 hours on 4 March 2019 and if she had acted upon that advice.

Mira-Belle Bosch

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. 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. 

Defects in systems of working

Leo Lamont

There was no guidance or checklist to assist triaging midwives in the assessment of preterm labour symptoms at the Princess Royal Maternity Hospital, Glasgow, and no guidance that a lower threshold ought to be applied when advising women to attend for assessment when preterm labour is suspected. These were defects in the system of working at the maternity assessment unit in the Princess Royal Maternity Hospital, Glasgow which contributed to Leo’s death.

Ellie McCormick

The lack of an effective means of flagging or highlighting risks and complications in Ms McCormick’s pregnancy was a defect in the system of working which contributed to Ellie’s death.

Mira-Belle Bosch

The interpretation and application of NHS Lanarkshire guidance advising a wait of up to 47 hours after a woman’s waters have broken before induction of labour was a defect in a system of working which contributed to Mira-Belle’s death

Recommendations

The Sheriff Principal made the following recommendations:

1. Greater Glasgow and Clyde Health Board should develop a ‘trigger list’ to identify and assess preterm (early) labour symptoms and create guidance on when women should attend for clinical assessment, specifying a low threshold. This should be shared with all health boards in Scotland.
   
2. All health boards in Scotland should review the information displayed on electronic records relating to previous preterm births and consider the creation of an automatically generated critical alert for previous preterm labour where one does not exist.
3. A procedure should be introduced to ensure appropriate handover when there is a planned change of named midwife. This should be stored electronically and draw attention to any prior complications or risk factors.
4. A system should be developed to allow a note to be added to a patient’s electronic records to highlight a further reason for a referral to a pre-existing appointment with a consultant.
5. The Electronic Record Keeping Guidance and Audit Tool issued by the Royal College of Midwives should be reviewed to address situations where midwives may not have access immediately to electronic notes. 
6. Health boards should consider acquiring hand held ultrasound scanners to detect the presentation of a fetus when a women reports spontaneous rupture of membranes or attends for induction or augmentation.
7. Consideration should be given to how the engagement of the presenting part can be better recorded and, specifically, to whether an assessment of ballotability should be recorded.
8. Each maternity unit in Scotland should introduce a telephone line (a red phone) for sole use by Scottish Ambulance Service crews giving them direct access to maternity units.
9. Consideration should be given to the introduction of video facilities to aid communication between paramedics and midwives or obstetricians in emergency situations.
10. Questions posed by healthcare professionals should make it clear that they relate to both the present situation and prior medical history. Health boards should review their electronic record system to ensure that the pre-populated questions ensure this. 
11. If “worsening advice” is provided i.e. advice to call back if symptoms do not improve upon taking painkillers, women should be provided with an approximate timeframe in which to do so.

Condolences

Sheriff Principal Anwar offered her condolences to the parents of Leo, Ellie and Mira-Belle in her determination, and recognised the toll that such cases also take on healthcare professionals.

The determination states: “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.  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 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.” 

The full Determination is available on the Scottish Courts and Tribunals Service website and is the only authoritative document.