A mother whose newborn daughter died following failings in care is campaigning to improve maternity safety after an inquest concluded neglect contributed to the death.
Charlotte Middleton died 40 minutes following her birth after Hinchingbrooke Hospital staff failed to act upon warnings which meant she was born two hours after she should have been, a coroner ruled.
Her mother Laura, 40, was diagnosed with gestational diabetes – she had the condition during two previous pregnancies – and her blood sugar levels should have been monitored. She and then husband Chris had discussions with midwives and doctors and opted for an elective caesarean section at 37 weeks.
Upon admission to hospital on July 17, 2019, Charlotte’s heart rate was monitored using a cardiotocography (CTG) machine. Next morning, Charlotte’s heart rate was found to have slowed and Laura was taken to theatre for delivery. Charlotte was born at 9.54am and died shortly afterwards.
Laura instructed medical negligence experts at Irwin Mitchell to investigate her care under the North West Anglia NHS Foundation Trust and to support her family through the inquest process.
Now the family and legal team are calling for lessons to be learned. The trust admitted to “failings in ante-natal care” which “at least materially contributed” to Charlotte’s death.
An inquest at Cambridgeshire and Peterborough Coroners’ Court concluded Charlotte died as a result of complication of maternal diabetes in pregnancy and neglect contributed to her death.
Coroner Lorna Skinner QC found staff did not act upon Laura’s blood sugar level readings and an abnormal CTG reading that should have seen Charlotte delivered by 7.40am. Had she been delivered by then, she would have survived, the coroner ruled.
The trust has since introduced a scheme called ‘Charlotte training’ to help prevent further neonatal deaths.
Irwin Mitchell’s Guy Forster, who represented Laura, said after the inquest: “We thank the coroner for such a thorough investigation and acknowledging the part serious failures in care had in causing Charlotte’s death. The tragic but inescapable truth is Charlotte’s death was entirely avoidable.
“We welcome the hospital trust’s acknowledgement that Laura should have received better care in a variety of respects, the changes they have made and their pledge to improve maternity safety through training named after Charlotte.”
The coroner raised concerns about a lack of out-of-hours specialist diabetologist provision at Hinchingbrooke and a lack of staff training. She recorded a narrative conclusion.
Laura said after the hearing: “We were all really looking forward to having Charlotte in our lives, and Isabelle and Harry couldn’t wait to have a little sister.
“During my time in the hospital before Charlotte was born, I wasn’t told of any problems. To hear she had died was awful. When Chris arrived, I couldn’t bear to tell him. The senior midwife broke the news to him and brought Charlotte in. She put her into Chris’ arms and I watched his heart break. That will stay with me forever.
“Walking out of the hospital without our baby devastated us. Losing Charlotte is something we’ll never get over and we’ll never be the same. While we can’t change what’s happened, we’re determined to campaign to improve care for others.
“Now the inquest is over we can move forward more positively knowing that Charlotte’s death wasn’t in vain.”
Dr Kanchan Rege, chief medical officer and deputy CEO at North West Anglia NHS Foundation Trust, which runs Peterborough City, Hinchingbrooke and Stamford Hospitals, said: “Following a thorough investigation, the trust has ensured lessons have been learned in this tragic case and further training has also been put into place in order to prevent this from happening again.
“The safety of the women in our care during pregnancy has always been paramount and ensuring the healthy delivery of a baby is something we strive for in every birth. We have been in touch with the family throughout and offer our sincerest condolences and continued support, should they require it.”