Blackpool Victoria Hospital doctor "truly sorry" as inquest finds baby girl died after fatal mistake

Ayla Marilyn Newton sadly died two weeks after mum Shannon Lord, 27, gave birth at Blackpool Victoria Hospital on January 26, 2023.

Yesterday, a two-day inquest into baby Ayla’s death concluded in Blackpool with the hospital’s chief nurse and senior obstetrician both issuing apologies to parents Shannon Lord and Dayle Newton.

Coroner’s findings

HM Coroner Margaret Taylor said: “Ayla Newton died at the age of 13 days at the Royal Preston Hospital.

“On January 25, 2023 her mother was admitted to the Blackpool Teaching Hospital for induction of labour as she was past her due date.

“At 9pm her membranes ruptured spontaneously. She was taken to the delivery suite at approximately 2am on January 26.

“A CTG to monitor Ayla's wellbeing was commenced at 3.12am. The trace was abnormal from the outset.

“A registrar was asked to review the trace at 3.38am and classified it as suspicious. A decision was made to continue to monitor Ayla.

“The abnormal trace mandated a decision to deliver Ayla by caesarean section by 3.27am which would have resulted in Ayla's delivery by 4.08am.

“Following a further review of the CTG trace, which remained abnormal between 4.25am and 4.35am, a decision was made to proceed to caesarean section.

“Ayla was born in a poor condition at 5.03am. She required resuscitation and intubation immediately after birth.

“Following stabilization she was transferred to Preston Hospital where she was diagnosed with hypoxic ischaemic encephalopathy.

“Her neurological condition did not improve and she died on February 8, 2023.

“On the balance of probabilities the delay in proceeding to caesarean section materially contributed to Ayla's poor outcome and her death.”

Official cause of death

The Blackpool and Fylde coroner concluded that Ayla’s medical cause of death was ‘hypoxic ischaemic encephalopathy’ - where a baby's brain is deprived of oxygen and blood flow during birth.

She found a delay in acting upon “a grossly abnormal CTG trace” and in proceeding to emergency caesarean section at Blackpool Victoria Hospital materially contributed to Ayla's death.

What went wrong?

Two midwives expressed concerns for the 27-year-old mum-to-be after cardiotography (CTG) scans showed abnormal readings as she was about to enter labour.

But obstetrician Muhammed Sandow told them he had seen similar CTGs return to normal and opted to wait another 30 minutes.

A Cesarean was eventually carried out in the early hours of the morning when Shannon's baby Ayla was born one and a half hours after concerns were first raised.

She was floppy, pale, not breathing properly and suffered seizures. She was transferred to Royal Preston Hospital where she died aged 13-days-old on February 8, 2023.

Blackpool Teaching Hospitals has accepted failings were made in the care of Ayla and her mother and the outcome might have been different if the Caesarean had been carried out earlier.

What was said at the inquest?

An inquest in Blackpool on Monday and Tuesday heard how there was 'no conflict' on the ward after Dr Sandow's decision but midwife Jennifer Fogg told coroner Margaret Taylor how she had some misgivings over it.

She first raised her concerns at 3.38am when the first CTG was abnormal and wanted it reviewed after five minutes. Dr Sandow did not authorise a c-section until 4.25am.

Miss Fogg said: 'It was a difficult situation. I felt I was right to escalate my concerns but he said he had seen similar CTGs before and that it might normalise.

“He is an experienced obstetrician and he also mentioned that there are also risks associated with Caesareans.

“But I had a gut feeling something was wrong. I just had a really bad feeling.”

Asked about Dr Sandow - who she still works with - Miss Fogg added: “I think he is a very valued and trusted doctor.

“It was not the right decision that day but Dr Sandow has made many right decisions over the years and saved the lives of many mothers and babies in his time.

“He is a very competent doctor.”

The inquest heard Shannon went in to the Blackpool hospital in January 2023 when she was overdue although the it had been a perfectly normal pregnancy.

All CTGs scans were normal until just after she entered the delivery suite at around 3.25am. When it continued to appear abnormal the midwives alerted Dr Sandow who then made his decision to wait.

Dr admits “I should have taken action earlier”

He told the inquest he had seen two CTGs scans before that normalised within forty minutes.

But he added: “Looking back, if I had a similar case again I would call the consultant and say we ought to be preparing for a c-section. I should have taken action earlier.”

Dr Sandow then broke down as he gave evidence, adding: “In 15 years of practice this case is the one that has taught me the most lessons.

“I have changed my practice. Now I would contact the consultant right away if I had a difference of opinion with a midwife.

“I should not have waited 30 minutes.”

In tears he added: “I want to extend my condolences to the family. I wish I ...'”, he broke off.

The family are pursuing a civil action against the hospital.

In response to the coroner’s findings, Blackpool nursing boss Bridget Lees said she was “truly sorry” to Shannon and Dayle for any failings on the part of the hospital and its staff.

“We’re truly sorry” say Blackpool Vic

Bridget Lees, chief nurse, AHP and midwifery officer at Blackpool Teaching Hospital said: “Our deepest sympathies go out to Ayla’s family and loved ones, and we are truly sorry that our care fell below the standards they deserved.

"The safety of mothers and their children is of utmost importance to all of us and we have already undertaken a thorough and transparent investigation, reviewing our practices and completing a number of immediate actions.”

Ms Lees added: “"We have particularly focused on improving our governance processes and reviewing information sharing, training and education.

“We continue to work with external colleagues, including the Local Maternity and Neonatal System and the North-West Neonatal Operational Delivery Network.

"These actions, among others, ensure we continue to provide caring, safe, and respectful maternity services for the women and babies in our communities."

Representing Ayla’s family was stillbirth and neonatal death solicitor Eleanor Rostron.

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Statement from family’s solicitor

Ms Rostron said: “We do not believe that the hospital has demonstrated adequate insight into what should have been done differently to prevent Ayla’s death.

“Maternity staff should be aware of the importance of carefully monitoring both mother and baby not only throughout a pregnancy, but 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 baby Ayla in accordance with national guidelines.

“We have heard that the inexplicable delay in safely delivering Ayla was based on one doctor’s experience of two previous deliveries involving different mothers where pathological CTG readings had normalised.

“This was a dangerous assumption and goes against national guidelines designed to protect patient safety which mandated delivery in these circumstances.

“No one can predict that a baby’s abnormal heart rate will normalise. The repeated concerns raised by multiple midwives were ignored. The midwives also failed to escalate their concerns to the consultant in overall charge given that the obstetrician persisted in disagreeing with their correct observations.

“Continued monitoring of the CTG should have taken place and a timely c-section provided in order to prevent Ayla’s catastrophic injuries.

“The hospital failed to follow national guidelines and failed to prevent Ayla’s death. Shannon and Dayle are devastated and have lost trust in the hospital.

“We are not reassured that the medical staff involved in Ayla’s care have an adequate understanding of how catastrophic brain damage occurs 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 to her parents.

“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.”