Lack of information criticised in Montrose baby death case

Montrose Maternity Unit
Montrose Maternity Unit

A sheriff today (Wednesday) blasted a “paucity of information” between a specialist team and community midwives battling to save a sick newborn baby who died.

Sheriff Pino di Emidio made the scathing remark during a fatal accident inquiry into the death of Nevaeh Stewart, who passed away just hours after being born in a birthing pool at the maternity unit in Montrose Royal Infirmary in 2012.

He was responding to comments made by consultant paediatrician Dr Martin Ward-Platt of Royal Victoria Hospital in Newcastle, who said a new video link facility between neo-natal experts and midwifery staff facing emergency situations would be a “powerful tool” in the care of sick babies.

The expert told an inquiry at Forfar Sheriff Court that had a video link been in place when Nevaeh was born the “response could have been very different”.

The inquiry also heard Nevaeh may have died due to blood loss during labour.

Video technology is in the process of being brought in to help neo-natal specialists based at Ninewells Hospital in Dundee see sick babies in rural satellite maternity units that are staffed only by midwives.

Sheriff di Emidio said that while there was no video link available at the time, there was a telephone at the Montrose unit and staff could have used that to keep the flow of information going.

Dr Ward-Platt said he would “strongly advocate” the use of the new video system as “there’s nothing like being able to see the movement and the colour of the baby’s skin.”

He said: “If you can imagine someone looking down a video link at Nevaeh at 15 minutes — pale, floppy and unresponsive — a very plausible response to that would be 999. Just do it.

“That baby is sick and it could go badly.

“The response could have been very different to what it was.

“Telephone contact should be maintained until the video link is established — don’t just wait for the Rolls Royce technology, use what you have.

“The quality of the judgment and the decision making should be a whole lot better and the response could have been very different to what it was.”

However Dr Ward-Platt said he had no criticism of the Montrose unit and said there was no human factor or human error which caused Nevaeh’s death and said the midwives were to be commended for their “assiduous and exemplary” actions in monitoring and resuscitating the child.

He added: “I have never seen a baby as regularly or frequently monitored as in this case.

“I didn’t identify any area of midwifery training which needs to be addressed. They competently and appropriately recognised that they needed expert help from the neo-natal team.”

Earlier Dr Julia Sanders, a consultant midwife, said: “There was no placental compromise, no evidence of infection, no fetal abnormality or maternal illness.

“There was a suggestion there may have been some blood loss around the time of birth.

“A small tear has been noted in one of the vessels near the placenta.”

Dr Sanders said damage to the umbilical cord “seems to be more common” in water births - around one in 500 births - but that the tear was located further inside the body than could have been affected.

Nevaeh Stewart died just three-and-a-half hours after she was born in a birthing pool at Montrose Royal Infirmary’s community midwife unit on September 30, 2012.

A fatal accident inquiry into her death is being held at Forfar Sheriff Court - where her father, Gary Stewart, 30, of Auchenblae, Aberdeenshire, earlier described the unit as an “emergency response blackspot”.

That was after notes made by midwives showed they had noted a neonatal transport team as being “en-route” from Ninewells in Dundee at 5.40am - but did not arrive until 7.15am.