A baby girl died from a serious brain injury because midwives failed to provide basic medical care, a coroner has concluded.
Ida Lock, who lived for just seven days, was born at the Royal Lancaster Infirmary in November 2019 but suffered a brain injury caused by a lack of oxygen.
She was transferred to intensive care at Royal Preston Hospital’s neonatal unit where she died a week later on 16 November 2019.
Ever since her death, Ida’s grieving parents, Ryan Lock and Sarah Robinson, have had to fight for answers.
Mr Lock said the hospital’s trust “put up a huge wall” when they tried to find out what had happened.
Ms Robinson says she was made to feel like she was to blame.
“It was was awful. It was so tough. My world had shattered, and I couldn’t figure out what had gone wrong, what I’d missed.”
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An initial investigation carried out by the University Hospitals of Morecambe Bay NHS Trust found no issues with her delivery.
However, in April 2020, a report from the independent Healthcare Safety Investigation Branch (HSIB) identified numerous failings in the care of Ida which contributed to her death, the hearing at County Hall, Preston, had previously heard.
Ms Robinson says: “That’s the hurt, because that time that we’ve taken to fight and get these answers. And all along people had these answers, people knew, but they didn’t give them to us them.”
Midwives had failed to identify an abnormally slow foetal heart rate after Ms Robinson attended in early labour and then following birth there was ineffective resuscitation, the HSIB concluded.
This trust has faced serious criticism in the past.
A review into maternity care at Morecambe Bay in 2015 found 11 babies and one mother had died due to poor care.
The report’s author, Dr Bill Kirkup, gave evidence at the inquest and told Sky News it is “unforgivable” lessons have not been learnt.
He also chaired an investigation into maternity services in East Kent and found repeated and significant failings.
“These are not problems of isolated units, and it’s not a particular rogue unit that we’re talking about here. It’s a very widespread failure of culture in maternity services,” said Dr Kirkup.
The national maternity inspection programme carried out by the healthcare regulator the Care Quality Commission (CQC) assessed over 130 units.
It gave ratings for safety and found 65% rated either “inadequate” or “requires improvement”.
Mr Lock believes there must be a change in culture.
He said: “There needs to be more accountability. If people feel they can get away with being deceitful and covering up the truth, then they’re going to continue doing that.”
Ms Robinson has since had another baby daughter but says her mental health has suffered.
“It’s changed me as a person. Five years on, the anxiety, the stress, it’s just constant. No one was open and honest with us. No parent should have to go through that.”
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The family scattered Ida’s ashes on Morecambe Beach, close to their home.
Mr Lock says they often walk along this small stretch of sand which they call “Ida’s beach”.
He said: “She’s always going to be in our hearts, and that’s what’s driven us to continue, to keep going. We owe it to her.”
Delivering a narrative conclusion following the inquest on Friday, HM Senior Coroner for Lancashire, Dr James Adeley, said: “Ida was a normal child whose death was caused by a lack of oxygen during her delivery that occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress.”
He added her death was contributed to by the lead midwife’s “wholly incompetent” failure to provide basic neonatal resuscitation for Ida during the first three-and-half minutes of her life, which further contributed to the infant’s brain damage.
Dr Adeley identified eight missed opportunities by midwives to alter Ida’s clinical course.
