Healthcare safety investigators make recommendations after death of baby girl

Charlotte Emma Warkcup died in December 2021, and findings at an inquest led a coroner to call into question the safety of South Tyneside District Hospital’s midwife-led birthing centre.

Following Lottie's death, an investigation was launched by the Healthcare Safety Investigation Branch (HSIB) after a number of failings were highlighted by her parents in the run-up to their daughter's birth.

The report found:

::The mother had did not received sufficient balanced information and support to enable her to make an informed choice about her place of birth;

::A diagnosis of latent phase of labour was made, on her arrival, which meant staff did not initiate a labour schedule of IA.

::The report also stated there were differing recollections of Mrs Warcup being in the second stage of labour and records were not clear. It added a VE (vaginal examination) was not undertaken when the mother began to push, and there was no increase in the frequency of IA which may have identified concerns about the Baby's heart rate sooner and led to an earlier recognition of the need to transfer the mother to the OLU.

::After arrival to the hospital (Sunderland) the access card was not working which led to a delay of 11 minutes in moving to the DS (Delivery Suite)

::There was no one in the room when the mother arrived and this led to the perception of the DS being “not ready”. Being greeted on arrival would have enhanced the mother's experience of care and provided oversight and support for staff.

The report went on to make a number of recommendations including:

::The Trust to ensure mothers are provided with evidence based, balanced information to be able to make informed birth place choices;

::Staff are supported to diagnose active labour in line with national guidance and initiate intrapartum observations

::To ensure staff are supported to recognise delay in the second stage of labour and consider the additional time taken for transfer to an obstetric unit

::Staff are supported to recognise and respond to the second stage of labour with an increase in IA in line with national guidance.

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.