Jessop Wing Sheffield: Hospital bosses given six weeks to respond over action plan after newborn baby’s death
and live on Freeview channel 276
Millie-Rae Needham was born at the trust’s Jessop Wing maternity unit on August 6, 2020, at 1.56am, and sadly died at the antenatal unit three days later, on August 9, 2020.
She was Skinna Beckingham's second child after 10 years and her mother had had a healthy pregnancy.
Sheffield Coroner's Court, which held an inquest into her death earlier this week, has ruled that 'neglect' contributed to her death as there was a 23-minute delay in her delivery, after her heartbeat could not be located.
Assistant Coroner Abigail Combes said the baby's condition was 'not adequately monitored' and blamed this on 'individual failings'.
The court also heard from consultant neonatologist Dr Porus Bustani that Millie-Rae was a 'healthy infant and would have been born in a healthy condition' had there been no delay.
During the conclusion of the inquest on Thursday (February 17), the trust had agreed to comment on the action plan within six weeks, before a decision about a regulation 28 report 'to prevent future deaths' is made.
Trust to explain decision behind changes of care
The trust was also instructed to provide evidence around its decision to move Skinna, who was placed under consultant-led-care at first to midwife-led-care after her 40th week scan.
Ms Combes said: "One of the questions that I have around Skinna's particular case is, the scans were clearly showing that Millie-Rae was growing at a normal rate throughout the pregnancy.
"And it seemed an odd point at which to make a decision to move her to midwife-led-care at the 40 week scan. It might be perfectly normal, it might be perfectly within guidance. It just seemed a little bit of an odd point at which to make that decision.
"Whilst I accept entirely the evidence that there is a process by how those decisions are made, I just want to understand in more detail."
In addition to that, the trust is also required to provide a report on how it trains staff in carrying out episiotomy, a procedure done to make vaginal opening larger for childbirth.
During labour, episiotomy had to be performed to make way for Millie-Rae's birth, approximately 20 minutes after Skinna did not make any progress despite positional changes.
Millie-Rae was born in ‘poor condition’
The inquest heard that the procedure was performed at 1.55am and Millie-Rae was born at 1.56am in 'poor condition' where she appeared 'pale and floppy' and was making no respiratory effort.
The neonatal team arrived a further four minutes later and noted that Millie-Rae’s heart rate had become undetectable and a consultant during the crash team and cardiopulmonary resuscitation with chest compressions was also present.
After 10 minutes, Millie-Rae's heart rate returned to between 60 and 100 beats per minute and over 100 beats per minute after one minute.
The baby was then transferred to the neonatal unit, where despite the efforts of the neonatal team, she died at 10.35pm on August 9.
The post-mortem examination concluded that her cause of death was a hypoxic ischemic encephalopathy where the brain doesn't receive enough oxygen or blood flow.
NHS Sheffield Teaching Hospitals Trust declined to make any further comment when contacted.