The deaths of three newborn babies could have been avoided if “reasonable precautions” had been taken, an inquiry has found.
Leo Lamont, Ellie McCormick and Mira-Belle Bosch all died within hours of their births in two Lanarkshire hospitals in Scotland.
Leo was two hours old when he died at University Hospital Monklands on 15 February 2019, while Ellie was just five hours old when she died at Wishaw General Hospital a few weeks later on 5 March that year.
Mira-Belle was 12 hours old when she died on 2 July 2021 at Wishaw General Hospital.
Following the fatal accident inquiry, Sheriff Principal Aisha Anwar KC said “reasonable precautions” could have been taken that might “realistically” have saved each baby’s life.
In each case, the mothers had been in contact with a hospital in the hours before giving birth but had been advised to remain at home rather than go in for an assessment.
Leo’s mother Nadine Rooney had a history of preterm delivery and had reported episodes of bleeding during her pregnancy.
She was 27 weeks into her pregnancy when she called Princess Royal Maternity Hospital in Glasgow at 3.17am on 15 February 2019 complaining of “agony pains” in her back.
A midwife advised her to take painkillers and to call back if the pain did not improve, and she gave birth to Leo on her bathroom floor just before 5am.
At 7.10am, Leo was pronounced dead at University Hospital Monklands having suffered from a shortage of oxygen during and shortly after labour.
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Ellie’s mother Nicola McCormick had also reported episodes of bleeding during her pregnancy, but her observations had been considered normal.
She phoned Wishaw General Hospital’s maternity unit at about 4.30pm on 4 March 2019 to report that she was experiencing contractions. She was advised to take painkillers and have a bath or shower, and to call back if she was “not coping”.
When she called again at about 7.30pm, she was advised to go in. Her baby’s heartbeat was found to be slow so medics carried out an emergency caesarean section.
Ellie was pronounced dead at 2.20am having suffered a brain injury due to a lack of oxygen during labour.
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According to the inquiry’s report, the pregnancy of Mira-Belle’s mother Rozelle Bosch had gone smoothly.
She called the maternity ward at Wishaw General Hospital at about 8.50pm on 30 June 2021, reporting that her waters had broken and she was experiencing contractions.
Ms Bosch was discharged following an assessment. She phoned the unit again at about 2.30pm on 1 July and was advised to remain at home.
About eight hours later, her partner called for an ambulance, reporting that the baby was being born feet-first.
When paramedics arrived, they tried phoning the maternity unit for advice, and had to call five times before they got through.
After they attempted to deliver the baby in situ, Ms Bosch was taken to hospital, where Mira-Belle was delivered but found to be unresponsive.
She was pronounced dead at 12.30pm on 2 July, having suffered a brain injury due to a lack of oxygen.
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In her report, Ms Anwar offered condolences to the bereaved parents, who she said had given evidence “with great dignity” during the inquiry.
The report makes 11 recommendations, including the drawing-up of a “trigger list” for identifying preterm labour symptoms, and the introduction of a dedicated telephone line to give ambulance service staff direct access to maternity units.
It also recommends that women are given an “approximate timeframe” in which to call back when told to see if symptoms improve after taking painkillers, as well as recommending improvements in the way information is recorded on hospital systems.
Scotland’s public health minister Jenni Minto said she would “consider the findings carefully with the maternity community” and ensure that the sheriff’s recommendations “are acted upon promptly”.
