Failings at Nottingham maternity unit before baby death, inquest finds

Kahlani Rawson died at Nottingham City Hospital's neonatal unit on 15 June 2021

A four-day-old baby died after "failings in care" led to a 20-minute delay in carrying out an emergency Caesarean section, a coroner has said.

Kahlani Rawson died at Nottingham's City Hospital from a lack of oxygen to the brain and complications from a placental abruption.

An inquest heard the matter was not escalated at the earliest opportunity by staff and this could have "changed the outcome".

Hospital bosses have apologised.

Emergency number

Nottingham Coroner's Court heard the Rawson family contacted the maternity triage desk from home on the morning of 11 June 2021 to report bleeding and that the baby had not moved for 24 hours.

Ms Rawson was advised to come to hospital to be assessed but a triage midwife told the inquest she could not be certain she had informed colleagues the baby was not moving.

The midwife on shift who looked after Ms Rawson, told the hearing: "When you hear that, your heart is in your throat. I don't remember hearing that."

The hearing also heard that the midwife described a scan as "sub-optimal" but said on reflection "abnormal" would have been more appropriate.

The midwife also said she "should've dialled" the emergency 2222 number sooner when Ms Rawson lost more blood.

A registrar also conceded she should have dialled the emergency number sooner when reviewing the mother.

Ms Rawson was eventually transferred to theatre and her baby was born by emergency Caesarean section at 09:17.

The inquest was told the newborn was "pale, floppy and not breathing" and subsequently required resuscitation.

He was then transferred to the neonatal unit but died on 15 June.

Scan mistakes

Nottinghamshire assistant coroner Dr Liz Didcock said the placental abruption was likely to have started "hours, rather than minutes" before birth.

But the coroner said CTG scans were "misinterpreted" by a midwife and a registrar which led to "reassurance and ambiguity" of the situation.

Giving a narrative conclusion, Dr Didcock said she would not be submitting a prevention of future deaths report as she was satisfied the hospital trust had implemented changes around more structured handovers and escalation training.

"The trust accept there were failings in the care which resulted in this 20-minute delay in delivery," Dr Didcock said.

"Without the 20-minute delay, Kahlani would not have died.

"While the likely extension of the abruption which led to further brain hypoxia was recognised, there was a delay of around 20 minutes in the delivery of Kahlani as a CTG was not reviewed."

NUH's own rapid review meeting concluded there "should have been earlier intervention" which would "more than likely changed the outcome".

Sharon Wallis, director of midwifery at NUH, said they were "deeply sorry" they "missed opportunities" to deliver Kahlani earlier.

"We offer our sincerest condolences to Ms Rawson and her family," she said.

"We are committed to improving our service and have made a number of changes to ensure that we can make a difference to how we care for women and families.

"We owe it to Ms Rawson and her family, and to all the families we have failed, to make improvements and to deliver a better maternity service for our communities."

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