A baby girl who suffered fatal oxygen deprivation would have survived had an obstetrician listened to ‘repeated’ concerns of midwives and ordered an immediate c-section, a coroner has found.
But emergency delivery was not ordered and Ayla Newton was born floppy, pale, not breathing properly and suffering seizures.
She died 13 days later after being taken to another hospital for specialist treatment.
After the verdict, the infant’s devastated parents revealed they have still not received an apology and said they ‘do not believe’ hospital bosses have ‘demonstrated adequate insight into what should have been done differently to prevent Ayla’s death’.
Ayla was found to have suffered Hypoxic Ischemic Encephalopathy, resulting in serious damage to the brain, heart, liver and kidneys from lack of oxygen at birth.
The two-day inquest, in Blackpool, Lancashire, heard cardiotocography (CTG) monitoring equipment showed heart abnormalities nearly 90 minutes before birth – but locum obstetrician, Dr Muhammad Sandow, took no action, believing the readings would ‘stabilise’.
Shannon Lord and Dayle Newton with their baby daughter Ayla before her death aged 13 days
Giving her conclusions on Tuesday, Coroner Margaret Taylor said: ‘The clinical decision of (Dr Sandow) was incorrect. The safest option would have been to proceed to a Caesarean section.’
Ms Taylor told Ms Lord, 27, and her partner Dayle Newton, 36, that delays before a Caesarean-section eventually took place had ‘on the balance of probabilities contributed to your daughter's poor outcome and death’.
The coroner said Ms Lord had the right to expect to go home with a healthy baby girl after a normal ‘low risk and uneventful’ pregnancy before she went into labour at Blackpool Victoria Hospital.
But, in a narrative verdict, the coroner refused to make a neglect finding against Blackpool Teaching Hospitals NHS Trust during Ayla’s birth on January 26, 2023, saying the delay in ordering a C-section was ‘not evidence of a lack of basic care’.
‘The interpretation of CTG results is an art that requires specialist knowledge,’ she said.
Reading a statement on behalf of Ayla’s parents, solicitor Eleanor Rostron said: ‘Maternity staff should be aware of the importance of carefully monitoring both mother and baby up until a baby is safely delivered.
‘Ayla’s heart rate was shown in real time and grossly abnormal results were clear from the outset and for a prolonged period. This should have triggered an emergency medical intervention to deliver Ayla in accordance with national guidelines.’
Shannon Lord said she is 'not reassured' that medics understand the risk of brain damage
In their statement, the parents added: ‘The repeated concerns raised by multiple midwives were ignored. The midwives also failed to escalate their concerns to the consultant in overall charge.
‘We are not reassured that the medical staff involved have an adequate understanding of catastrophic brain damage or the importance of acting timeously on an abnormal heart rate reading.
‘The hospital has admitted that it failed to save Ayla’s life but have yet to issue a full and formal apology.
‘We have heard that lessons have been learned and sincerely hope that is the case however, failings will continue if the coroner’s court fails to recognise and address gross failings in care.’
Ms Lord and Mr Newton arrive at Blackpool Town Hall for the inquest into Ayla's death
During the inquest, Ms Lord and Mr Newton - both adult support workers – had earlier told how they are ‘extremely angry and will never get over the loss of our first child’.
They added: ‘It is devastating to know now that had the midwives’ repeated concerns been actioned, Ayla would be with us today.’
The inquest heard Dr Sandow had a ‘difference of opinion’ with midwives Jennifer Fogg and Mandy Benton over the CTG readings.
Both women were worried about abnormalities but neither escalated their concerns to the consultant in charge of the ward, Dr Reem Nasur, after Dr Sandow had 'reassured' them he had seen similar results before.
One CTG reading, at 3.12am, was described by expert witness Dr Malcolm Griffiths as ‘so grossly abnormal it should have mandated a Caesarean immediately’.
A further abnormal CTG reading occurred at 3.38am but it was not until 4.35am that Dr Sandow authorised a C-section.
Dr Sandow broke down in tears at the inquest and apologised to Ms Lord and Mr Newton for the loss of Ayla, who later died at Royal Preston Hospital.
His shoulders shaking with emotion, he told the couple: ‘I should not have waited. I want to extend my condolences.’
Dr Muhammad Sandow has apologised for the delay to ordering a Caesarean section for Ayla
The family are pursuing a civil action against the hospital. They later had a second baby girl but opted to have the child delivered at the Royal Preston Hospital.
Ms Taylor refused to order a Prevention of Future Deaths report, which would have recommended urgent action, after being assured by counsel for the hospital trust, Nichola Halpin, and senior obstetrician Eric Mutema, that it had introduced new guidelines.
Blackpool Teaching Hospitals has accepted failings and that the outcome might have been different had the Caesarean happened sooner, the inquest heard.
