Coroner questions safety of midwife-led birthing centres after death of baby girl following failings at South Tyneside District Hospital

Sunderland coroner Derek Winter raised his concerns during the inquest of Charlotte Emma Warkcup, who died on December 23, 2021, at Sunderland Royal Hospital, aged 60 hours and 10 minutes.

The inquest heard how seconds after she was born, doctors immediately had to carry out resuscitation lasting 22 minutes, in a desperate bid to revive her.

RELATED: Family tell of heartbreak after baby girl dies following failings at South Tyneside's birthing centre

However, the damage had already been done prior to her arrival at the hospital from the midwife-led birthing centre based within the grounds of South Tyneside Hospital after midwives failed to correctly care and monitor her mother Emma Warkcup during labour or act swiftly when complications arose.

Lottie was suffering from foetal bradycardia – when a baby's heart rate drops below baseline and is generally associated with hypoxia – oxygen starvation.

Health chiefs have apologised to her family and vowed lessons have been learned and changes made, including better information provided to parents and staff drills.

Mr Winter has now called for action from the Secretary of State for Health and Social Care as part of a Report to Prevent Future Deaths, which highlighted his concerns over the safety of standalone midwife-led birthing centres.

He has also called on the Government to look at the recruitment and retention of midwives to ensure continuity of care, after Mrs Warkcup was seen by several midwives throughout her pregnancy, and to look at ways to improve detection of babies who are of small gestational age.

Mr Winter said: “Appropriate care at the centre could not be provided because the centre had no provision for it, which is why it had to be procured elsewhere.

“This was a medical emergency, and time was of the essence, the situation was time critical.”

A six-day inquest held at Sunderland City Hall heard a number of failings were made at the birthing centre in the care of Mrs Warkcup.

Mr Winter also said he had “little or no confidence” in some of the evidence presented at the inquest, adding he found ‘some comments and actions bizarre and not conducive to the safe management of labour’.

Mrs Warkcup and her husband David had initially decided Lottie would be born at Sunderland Royal Hospital, but changed their mind as Covid regulations meant Mr Warkcup would not be able to be present until the active stages of labour.

They then chose the Queen Elizabeth Hospital in Gateshead, but after visiting South Tyneside, they were persuaded to choose there instead.

The couple claimed they were not given full information around the risks of giving birth at the centre and the time it would take for transport to Sunderland Royal Hospital in an emergency – this was agreed by the Trust.

Mrs Warkcup said: “When I was asked at one of my ante-natal appointments where I was giving birth, I said Gateshead and they said have you not thought about the birthing centre, and I said no as it didn't have a consultant. But she was really persistent about it and made it out to be a wonderful place."

Mrs Warkup said the couple decided to have a look, and were shown round by a member of staff.

“She took us into the birthing pool, and it was lovely, she said it was only staffed by experienced midwives and that they could spot the signs when labour wasn't progressing and that they would get you straight up to Sunderland and snapped her fingers,” she said.

“They made me feel very calm and being from South Shields, I thought it would be nice for my baby to be born in South Shields, so I was insistent with Davey to have Lottie born there. I was not given a full account of the risks of having my baby at the centre.”

The inquest heard when Mrs Warkcup made her way to the centre after feeling contractions on December 20, she was incorrectly categorised as being in the latent stage of labour rather than the active stage.

A number of failings during the course of the night followed including a delay in recognising the second stage of labour and the delay in calling an ambulance when it was discovered Lottie's heart rate was falling at 2.52am.

An ambulance was not called until 3.17am.

The inquest heard when the couple arrived, the midwife's access card was not working and the out-of-hours call system had to be used to alert staff to their arrival.

Staff at the hospital were also unaware of the extent of the emergency, and while the ambulance service were told Lottie was suffering from foetal bradycardia – a medical emergency – that diagnosis was not used in a telephone call to Sunderland Royal Hospital.

It was this delay in calling the ambulance, the inquest heard, which was critical and resulted in what Dr Sarah Gattis described as a “catastrophic” outcome for Lottie and her family.

She said: “The delayed transfer and associated loss of opportunity for increased monitoring and earlier delivery from 2.52am onwards is more likely than not to have contributed to the catastrophic outcome for Charlotte and her family.”

The inquest heard a meeting following Lottie's death between the family and neonatal consultants at the trust, noted Dr Rachel Hartis informing the family “we failed you, we have failed you on at least two accounts” and “we harmed your baby.”

A number of other failings were heard at the inquest.

They included, but are not limited to:

::The failure to conduct and update a risk assessment and follow SBAR protocol during the course of the mother's labour;

::The missed opportunities on behalf of the midwifery team at the centre to perform vaginal examinations to directly identify the stage of labour and obtain a full clinical picture; and

::The inadequate, inaccurate and inconsistent recordings of Lottie's heart rate and condition of medical notes and on the partogram

::The failure on the centre's part to manage risk during mother's labour

::The failure to monitor Lottie's heart rate at the correct times and frequencies, in accordance with guidelines

::The failure to identify a delay in the second stage of labour and to determine when mother needed to be transferred to Sunderland Royal Hospital and

::The failure to expedite the transfer in accordance with the severity of the situation

::Lack of basic communication between midwives at the centre

::Lack of of basic communication with Lottie's parents during mother's labour

::Lack of basic communication between the centre and Sunderland Royal Hospital.

Mr Winter said: “In my view there were individual, ongoing and cumulative failures of basic care to somebody in a dependent position with an obvious need for that help.

“If I applied the legal test submitted to me by the Trust, I would form the same view on the evidence – the threshold for neglect is made out.

“Time was of the essence here. People should have been acting upon the very things that were obvious.

“The transfer from the centre to Sunderland Royal Hospital was not good enough.”

The inquest heard a number of changes have been carried out since Lottie's death including more information contained in leaflets given to expectant mums, when a transfer is needed to Sunderland Hospital staff are ready and waiting to ensure no delays in transfer from the ambulance to where the expectant mum is needed to be, and a more stringent checklist when relaying information between the centre and the hospital.

Mr Winter concluded Lottie died of natural causes contributed to by neglect.

In a statement after the inquest concluded, Melanie Johnson, Executive Director of Nursing, Midwifery and Allied Health Professionals at South Tyneside and Sunderland NHS Foundation Trust, said: “On behalf of the Trust, I want to say sorry to Lottie’s family for our failures in care to their little girl.

"There is nothing we can say that will ever ease the pain of losing their baby and no words to adequately express the sorrow we feel in the loss of young Lottie so early in her life.

"There were things that we got wrong and we fully accept the independent findings of the investigation by the Healthcare Safety Investigation Branch (HSIB) and the Coroner’s report.

"The loss of Lottie will always lay heavy in our hearts and I want to reassure her family of the steps we have taken to correct the things which went so tragically wrong and the huge amount of learning that has come from this case.”