Hospital failings contributed to deaths of three newborn babies – inquiry

Had ‘reasonable precautions’ been taken, Leo, Ellie and Mira-Belle might still be alive

Wishaw General Hospital in North Lanarkshire, where two newborn babies died (Google Maps)

The deaths of three newborn babies in Lanarkshire hospitals could have been avoided, an inquiry has found.

Sheriff Principal Aisha Answar KC concluded that "reasonable precautions" could have prevented the tragedies.

The inquiry examined the deaths of Leo Lamont, Ellie McCormick, and Mira-Belle Bosch, who died within hours of their births.

Two-hour-old Leo died at University Hospital Monklands on February 15, 2019.

Just weeks later, on March 5, five-hour-old Ellie died at Wishaw General Hospital. Mira-Belle died at the same hospital on July 2, 2021, aged 12 hours.

In each case, the mothers had contacted the hospital before giving birth but were advised to remain at home.

Sheriff Answar KC’s report highlighted systemic issues within the hospitals, including inadequate guidance for midwives assessing preterm labour symptoms and a lack of effective systems for flagging high-risk pregnancies.

It also flagged issues with the interpretation of guidance around when to induce labour after a woman’s waters have broken.

Leo Lamont died at University Hospital Monklands (PA Archive)

Leo’s mother Nadine Rooney had a history of preterm delivery and had reported episodes of bleeding during her pregnancy.

She was 27 weeks into her pregnancy when she called Princess Royal Maternity Hospital in Glasgow complaining of “agony pains” in her back.

A midwife advised her to take painkillers and to call back if the pain did not improve, and she gave birth to Leo on her bathroom floor about an hour and a half later.

Mother and child were rushed to University Hospital Monklands but Leo was pronounced dead, having suffered from a shortage of oxygen during and shortly after labour.

Ellie’s mother Nicola had also reported episodes of bleeding during her pregnancy, but her observations had been considered normal.

She called the maternity unit to report that she was experiencing contractions, and was advised to take painkillers and have a bath or shower, and to call back if she was “not coping”.

When she called again about three hours later she was advised to go in. Her baby’s heartbeat was found to be slow, so she underwent an emergency Caesarean section.

After being delivered, baby Ellie was in “poor condition and there were no signs of life”.

She was pronounced dead at five hours old, having suffered a brain injury due to a lack of oxygen during labour.

Public Health Minister Jenni Minto has welcomed the report (PA Archive)

According to the report, Mira-Belle’s mother’s pregnancy had gone smoothly.

She called the maternity ward at Wishaw General Hospital at about 8:50pm on June 30 2021, reporting that her waters had broken and she was experiencing contractions.

She went in for an assessment but was discharged, and called the unit again at about 2:30pm on July 1 and was advised to remain at home.

About eight hours later her partner called for an ambulance, saying that that baby was being born feet-first.

When paramedics arrived they tried phoning the maternity unit for advice. However, they had to call five times before they could get through.

After they attempted to deliver the baby in situ, Ms Bosch was rushed to hospital, where Mira-Belle was delivered but found to be unresponsive.

She was pronounced dead at 12:30pm on July 2, having suffered a brain injury due to a lack of oxygen.

In her report, Ms Anwar said the bereaved parents had given evidence “with great dignity” during the inquiry.

“The death of a child is an unimaginable and deeply painful event in any parent’s life; one from which it is undoubtedly difficult to recover,” she said.

“What ought to have been a time of celebration for the parents and families who awaited the births of Leo, Ellie and Mira-Belle turned to one of sorrow and tragedy.”

The report made 11 recommendations, including the drawing-up of a “trigger list” for identifying preterm labour symptoms, and the introduction of a dedicated telephone line to give ambulance service staff direct access to maternity units.

It also recommended that women are given an “approximate timeframe” in which to call back when told to see if symptoms improve after taking painkillers, as well as recommending improvements in the way information is recorded on hospital systems.

Public Health Minister Jenni Minto said: “The loss of a baby is devastating for any family, and I offer my sincere apologies to the families for any failures in the system that led to the tragic deaths of babies Leo, Ellie and Mira-Belle.

“I am grateful to Sheriff Principal Anwar for her report, and will consider the findings carefully with the maternity community and ensure that her recommendations are acted upon promptly.”