Inquest begins into tragic 'avoidable death' of newborn at Lancashire hospital

Shannon Lord, 27, was admitted to Blackpool Victoria Hospital for a planned induction of labour in February 2023.

Sign up for Blackpool Gazette newsletter - essential local news.

The CTG showed that her baby’s heart rate was abnormal and the midwife escalated her concerns to the locum obstetrician with a view that mother and baby should be monitored every few minutes, and an emergency c-section performed if the baby’s heart rate did not normalise quickly.

Eleanor Rostron, the family's solicitor, said the obstetrician disagreed - “believing the CTG would normalise”, and planned to come back to check if the baby’s heart rate was within a normal range after an hour.

During this critical period, the CTG continued to show pathological results, said Ms Rostron, as several midwives raised repeated concerns with the obstetrician in order for an emergency medical intervention to proceed.

Join our new WhatsApp Community to get the latest news and top stories from across Lancashire directly to your phone

But the solicitor says the obstetrician “was not concerned”. An emergency c-section was eventually performed, and Shannon Newton’s baby, Ayla, was born more than one and a half hours after her abnormal heart rate had been detected.

She was born “pale, floppy and not breathing”. She suffered seizures and her care was transferred to Royal Preston Hospital, where she died two weeks later in Shannon’s arms.

Representing the family, stillbirth and neonatal death solicitor Eleanor Rostron said: “Ayla’s parents Shannon and Dayle were very much looking forward to the arrival of their first child.

“The pregnancy had been normal throughout. Medical professionals should be aware that even in low risk normal pregnancies things can still go catastrophically and unexpectedly wrong up to the early days and weeks after a baby’s birth.

“When Shannon arrived in the delivery suite for a planned induction, there was a delay in starting the CTG which is essential for checking that a baby’s heart rate is as it should be. A CTG provides an immediate reading in real time.

“The midwife reviewed the CTG, and correctly recognised potential fetal distress demonstrated by the severely abnormal CTG reading.

“She escalated her concerns to the locum obstetrician who was ultimately responsible for Shannon’s care.

“Her correct view was that the CTG should be checked every few minutes and an emergency caesarean performed if it continued to show a pathological reading. A persistent abnormal CTG over a 26 minute period at this point should have been recognised for the red flag that it was.

“Remarkably, the obstetrician disagreed on the basis of having experienced different pregnancies where a baby’s abnormal heart rate had normalised expecting that the same would occur during Shannon’s care.

“His approach was to ignore the concerns raised by several midwives. Sixty minutes following the first signs of an abnormal heart rate in an unborn child is a significant amount of time during which catastrophic brain injury can occur.

“A baby can tolerate around ten minutes from the signs of distress first appearing before brain damage begins. There is no safe medical reason to ignore a pathological heart rate reading for one hour – particularly given that 26 minutes had already passed since the heart monitor was started.

“In this critical window during which Ayla could and should have been saved, Ayla’s heart rate consistently showed abnormalities. The obstetrician was repeatedly alerted to the concerns of multiple midwives. He ignored their concerns on the basis of a dangerous assumption and against national standards and guidelines.

“While Ayla’s heart rate continued to show the need for an emergency delivery, she suffered catastrophic brain damage. Ayla should have been delivered via an emergency c-section at least 55 minutes earlier.

“We cannot understand the logic of ignoring danger signs when good care was simply continuing to watch the CTG reading for a few more minutes before timely action to deliver Ayla before serious harm was caused.”

Ayla’s parents, Shannon Lord, 27, and Dayle Newton, 36, both support workers for adults with learning disabilities, said: “We were not made aware of any concerns with Ayla’s health until she was delivered floppy, pale and not breathing. This was extremely traumatic.

“We didn’t know what was going on. A few days after our beautiful little girl was born, we had to make the decision to withdraw her care as a result of severe brain damage. We sat with our girl in our arms for eleven hours watching her slowly die.

“We are extremely angry and will never get over the loss of our first child together. Shannon believed it was her fault for the first few months until the hospital’s internal investigation advised us that they had made mistakes.

“We do not understand why this has happened. We trusted the hospital to keep Ayla safe and to deliver a healthy baby. It is devastating to know now that had the midwives’ repeated concerns been actioned, Ayla would be with us today.”

The family have since had another baby girl and opted to avoid Blackpool Victoria Hospital, travelling to Royal Preston Hospital instead.

Blackpool Teaching Hospitals NHS Foundation Trust has admitted liability and continues to employ the obstetrician.

The Trust was approached for comment.