Precautions could have stopped baby deaths - inquiry

The three deaths occurred between 2019 and 2021

"Reasonable precautions" could have prevented the deaths of three newborn babies, a fatal accident inquiry has found.

Leo Lamont, Ellie McCormick and Mira-Belle Bosch all died within hours of their births in two Lanarkshire hospitals, in 2019 and 2021.

The report found all three deaths could "realistically" have been avoided had different advice been given by midwives or procedures followed.

The McCormick family said they could "never have imagined" the amount of failures that led to their daughter's death and called it a "catalogue of errors".

The inquiry ruled "defects" within the system contributed to each death, including that there was a "lack of an effective means" to highlight risks in one of the pregnancies and that midwives had no guidance to assess preterm labour symptoms.

Sheriff Principal Aisha Anwar KC made 11 recommendations for the future, including creating a "trigger list" to identify and assess early labour symptoms.

Among these are reviewing electronic patient information records to improve alerts for at risk mothers, and having a direct telephone line to each maternity unit in Scotland for ambulance crews.

In a statement, the McCormick family said: "The family could simply never have imagined the scale of both the individual and systems failures that came to light during the inquiry.

"What seemed to be flaws with the electronic system of record keeping actually turned out to be a catalogue of errors with numerous opportunities to avoid the tragic outcome that followed.

"It was extremely difficult for the family to hear the evidence and reading the determination is bittersweet in terms of achieving some sense of closure but also learning once again how different things ought to have been."

The family added they hoped all the inquiry's recommendations would be implemented.

The family of Leo Lamont said they hoped "lessons are learnt" from the deaths, and thanked Sheriff Principal Anwar for the "sensitive manner" in which she conducted the inquiry.

Leo Lamont died on 15 February 2019 at University Hospital, Monklands

Leo Lamont died on 15 February 2019 at University Hospital, Monklands, just two hours after birth.

His family called the Princess Royal Maternity Hospital in Glasgow because mum Nadine Rooney was experiencing "agony back pains" – but the midwife triaging the call didn't spot it as a sign of preterm labour for her at 27 weeks.

This was despite Ms Rooney being considered a high risk pregnancy, having previously given birth to a preterm baby and being a smoker.

She was instead advised to take painkillers, and gave birth less than two hours later on her bathroom floor at home.

By the time an ambulance crew arrived her son was blue in colour - known as cyanosed - and struggling to breathe.

He was later pronounced dead at University Hospital, and Sheriff Anwar found that had Ms Rooney been told to go to hospital the death could have been avoided.

Told to take painkillers

Ellie McCormick was considered a high risk pregnancy due to her mother Nicola having a high BMI.

She previously reported bleeding and reduced foetal movement but after examination her observations were considered to be within normal limits.

On 4 March 2019 she called Wishaw General Hospital to report that she was experiencing contractions, and was told to take painkillers and call back later if she continued to have problems.

Ms McCormick called back that evening at about 19:30 and was told to go to the hospital, where an emergency caesarean was carried out.

However, Ellie McCormick had been deprived of oxygen and died in the early hours of 5 March, about five hours after birth.

Experts agreed that had Ms McCormick been advised to come in at the time of her first call on 4 March Ellie would have likely survived.

She should have been advised of the need for induction at or before 40 weeks gestation during a previous assessment in February.

Five unanswered calls to medics

Mira-Belle Bosch died on 2 July 2021 at Wishaw General Hospital, 12 hours after her birth.

She had suffered a brain injury caused by a lack of oxygen during labour.

Her mother Rozelle called Wishaw General to report her waters had broken and she was suffering contractions on 30 June, but after attending the hospital was discharged.

The following day she again called about contractions and was told to remain at home, only to give birth that evening.

Paramedics who attended the scene then made further calls for assistance, including five calls to Wishaw General that went unanswered.

Sheriff Anwar found staff were too reliant on NHS Lanarkshire guidance to wait 47 hours after waters had broken before inducing labour and this had contributed to the death of Mira-Belle.

The inquiry stated Rozelle Bosch should have been asked to go for induction 24 hours after her waters had broken.

Sheriff Principal Aisha Anwar led the inquiry

Sheriff Anwar said she acknowledged the "pain and suffering" each family had been through with the deaths.

She said: "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.

"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."

Procurator Fiscal Andy Shanks, who leads on fatalities investigations for the Crown Office, said he hoped the inquiry would give the families "the answers they sought" after "overwhelming loss".