Doctors missed opportunities to save the life of a premature Sheffield baby following a four-hour delay in giving her mother an emergency caesarian, a coroner has ruled.
Two doctors on the Jessop Wing at the Royal Hallamshire Hospital misinterpreted heart rate readings from baby Marissa Buttery-Calvert while she was in the womb.
An inquest heard the four hour and 15 minute delay in delivering Marissa meant she was born unconscious.
Efforts to revive her failed and the baby girl was pronounced dead at just eight hours old.
If the emergency caesarian had been carried out earlier, she would have been born conscious and potentially could have survived the congenital pneumonia, a post-mortem found the baby was suffering from.
Coroner David Urpeth said: “The evidence suggests that on two occasions the abnormal heart trace was incorrectly read as normal.
“There was a delay in over four hours.”
He said the evidence suggested that if Marissa been delivered earlier she ‘would have been born alive and may, but only may, have survived with treatment’.
Mr Urpeth added: “At the very least, there were several missed opportunities to save Marissa.”
He told Marissa’s parents Michaela Buttery and Ricky Calvert, from Parson Cross: “One can only imagine the heartache caused by losing your child.
“It is hard to comprehend how difficult that must be. The evidence has suggested earlier intervention may have made a difference.”
He said he would have ordered a Preventing Future Deaths report had the inquest not already been told of the steps had been taken at the hospital to prevent such a tragedy occurring again.
Dr Marta Cohen said a post-mortem examination indicated Marissa had caught congenital pneumonia while in the womb.
She said in her opinion, the ‘advanced’ nature of her illness meant earlier intervention would not necessarily have saved the baby’s life.
“It is probable nothing could have saved Marissa,” she said.
Neither of the two doctors who misinterpreted the heart rate traces were at the hearing to give evidence and neither were named.
Lead consultant Roobin Jokhi said both doctors had accepted the findings of his report that mistakes had been made.
The inquest was told Ms Buttery was admitted to the Jessop Wing on November 30 last year when she was 35 weeks pregnant and her waters had broken.
The court heart she had spoken to midwife Donna Blackwell at 5.25am on December 2 to say she was bleeding.
At around 6.30am, she reported the bleeding was getting worse – resulting in a doctor being called.
Mr Jokhi said a junior doctor incorrectly classified the baby’s heartbeat as normal.
Nurse Blackwell said she was ‘reassured’ at the time by the doctor’s assessment, but ‘with hindsight’ said she could have asked a more senior doctor to review the readings.
Ms Buttery was examined around 90 minutes later by a more senior doctor who again incorrectly classified the heartbeat as normal.
Marissa was eventually delivered by emergency caesarian at around 11am – four-and-a-half hours after her initial assessment.
Mr Jokhi said her baby heart rate traces on the morning of December 2 showed ‘a marked change’ from the previous ones carried out on November 30 and December 1.
He said within 15 minutes of the first trace that morning, a plan should have been put in place for the delivery of the baby.
Mr Urpeth asked whether Mr Jokhi thought the outcome would have been different had that happened.
The consultant said if she had been delivered earlier ‘she may well have been alive but it would not be possible for anyone to say’ whether she would have survived the pneumonia.
Mr Urpeth said: “Probably she would have been alive at that point but you can’t say whether she would have survived. But she may have done.”
Mr Jokhi agreed there had been a ‘lost opportunity’.
He said both doctors have undergone a ‘period of retraining’, with all relevant staff given mandatory training on baby heart rate traces.
A hospital trust review found midwives had acted appropriately in relation to the care of Ms Buttery and her daughter.