Baby died after being half-delivered during ‘chaotic’ birth at NHS trust

A baby boy was starved of oxygen and died after being left half-delivered for almost a quarter of an hour during a “chaotic” breech birth in an NHS maternity unit.

Midwives failed to recognise baby Theo Ellis was in the breech, or bottom first, position until his mother Laura Ellis, 34, was already in advanced labour at Surrey’s Frimley Park Hospital.

What followed was a catalogue of errors by midwives and doctors who failed to heed the emergency and raised the alarm too late.

At one stage a paediatrician was made to stand outside the room by midwives while junior staff struggled to deliver Theo alone. A senior obstetrician was in surgery and a miscommunication by midwives and an on-call consultant meant she did not arrive until Theo was already dead.

After his parents brought legal action against the NHS, Frimley Park Hospital has now admitted mistakes led to Theo’s death in April 2019.

Ms Ellis and husband James are angry their son was classed as being stillborn which meant a coroner was not allowed to investigate his care during an inquest. There have been repeated calls to change the law to ensure the deaths of babies like Theo are investigated.

His mother told The Independent: “I walked in with a healthy baby. I’d looked after him for nine months and they killed him in the process of giving birth. The hospital get to write that he was stillborn, which obviously is a huge benefit to them, because the coroner can’t get involved, which to me is just staggering.

“When he was half delivered, he was still alive, and he had a heartbeat. But then at some point during that process he stopped having a heartbeat and died. When that was exactly, no one knows because they weren’t properly checking and they didn't realise his condition was actually deteriorating.”

She added: “It is a never-ending kind of torture I guess I will have to live with. You just don’t realise until it happens to you how many babies there are that should be here but aren’t because of these dreadful situations that are going on.”

An independent investigation of the case by the Healthcare Safety Investigation Branch (HSIB) found numerous mistakes by hospital staff that Ms Ellis said had echoes of the care scandals at Shrewsbury and Telford Hospitals Trust and East Kent Hospitals University Trust. Both hospitals are facing inquiries over poor maternity care.

In the weeks and days leading up to the birth chances to order an ultrasound scan that would have diagnosed Theo’s breech position were missed.

When she arrived at the hospital’s birth centre midwives did not carry out proper checks on Ms Ellis which could have detected the breech earlier.

The HSIB report found staff did not declare an emergency when they first realised Theo was in the breech position and that doing so would have meant senior staff were called to attend the birth earlier.

Investigators noted Theo was “delivered up to the scapula [shoulder blade]” by 6pm, adding: “The time from delivery of the umbilicus to delivery of the head would have been at least 13 minutes. The baby’s head was delivered … at 18.13 hours, seven minutes after the baby’s arms had been delivered.”

The report said: “The HSIB clinical panel felt that the delivery of the baby was significantly delayed, and that the delivery appeared disjointed.” It added Theo was starved of oxygen but there “was no perceived sense of urgency or recognition of the situation and no clear leadership” among staff in the room.

Ahead of the birth, Ms Ellis had made a birth plan that included minimal interventions and as few people in the room as possible. As Theo’s birth became an emergency the midwives failed to adapt and continued to keep staff out of the room.

The HSIB report said: “An agreement was made between staff that the paediatrician would wait outside the room until the senior midwife wanted them. The HSIB clinical panel suggested that staff continued to follow the mother’s birth plan rather than discuss the situation, and reasons for the need to deviate from the birth plan, with the family again.

“The majority of staff leading the delivery were junior or new in their roles … there was not enough expertise in the room to manage the delivery.”

The paediatrician outside the room did not know the baby’s heart rate was unable to be heard at 6.05pm but had they known could have called for emergency neonatal support earlier.

Ms Ellis told The Independent: “I really had no idea what was going on. This was so far from what I had envisaged being my birth, that obviously, if anyone had asked me, I would have said ‘I want whoever is most experienced here to help with this situation’.

“I want what is best for my baby. But for some reason, they never spoke to me about that. And instead asked experienced staff to wait outside the room. I just feel furious about that. Why didn't they ask me or realise this is not the best thing for the baby.”

After Theo was born attempts to resuscitate him were hampered when the oxygen cylinder for his resuscitative crib ran out. HSIB said Ms Ellis should have been put in a room with piped oxygen.

It added: “The family reported the resuscitation to be chaotic and observed the issues regarding the oxygen cylinder running out and attempts to contact the on-call senior paediatrician as well as additional equipment being placed on the floor in the way of staff.”

HSIB said the on-call obstetrician should have immediately come to the hospital when they were contacted at 6pm.

Ms Ellis went on to have her second baby, Josh, privately after losing confidence in the NHS and suffering panic attacks on the way to check-ups.

She said: “When you’re pregnant you can live in a kind of blissful ignorance that when you go into hospital you’re going into the safest place possible and they’re going to really look after your baby and everything’s going to be done for them when actually, we found that really wasn’t the case.

“It took way too long to realise that Theo was breech and by the time they realised, they could see his testes, so then their options were very limited of what they could do.”

Ms Ellis said it was wrong that Theo’s birth, on a Sunday, was more risky because of less senior staff being at work. She said: “If there had been an experienced consultant, Theo would be here. I am 100 per cent sure of that.

“None of the people that attended the birth went into it saying ‘I'm gonna let this baby die’. I don't feel angry for those people that were there.

“They made errors, but ultimately there should have been processes in place to stop those errors happening. The NHS does not have enough money to be able to have enough staff to give them all enough time to do proper training and if they had had proper training, and there was more people there, then Theo would have lived.”

Frimley Park Hospital has admitted liability for Theo’s death but a legal settlement has yet to be concluded with the couple’s law firm Leigh Day Solicitors.

A spokesperson for the trust said: “This is a tragic case and we are very sorry that our care for Mrs Ellis and baby Theo failed to meet the standards we expect of our maternity services.

“We have fully accepted and taken on board the findings and recommendations in the investigation report, and we met with Mr and Mrs Ellis to express our condolences for their sad loss and to apologise for the trust’s failings in care.”

The trust said it had implemented a number of changes, including requiring a full emergency response whenever a baby is found be breech and a consultant present at all breech births.

There have also been improvements in the process for calling consultants at home and ensuring women are properly examined on arrival, it added.