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Neglect contributed to baby's death

A baby died at the Royal Free Hospital as staff ignored calls for help. Clinical negligence partner at Leigh Day Sally Jean Nicholes is representing the baby's parents at the inquest.

Heather Paterson and Iain Croft

2 July 2007

Sally Jean Nicholes is representing the parents of Riley Croft who died of asphyxia 35 minutes after his birth on March 25, 2005 at the Royal Free Hospital in London.  An inquest jury at St Pancras Coroner's Court has found that neglect by medical staff contributed to his death.

The application of Prostin

Heather Paterson had experienced a normal pregnancy but she and her husband were turned away several times  when they arrived to have labour induced at the Royal Free in March 2005.  She was finally admitted two days after the original date for induction when she faced an eight hour wait to see a doctor.  A doctor failed to adhere to the hospital's own guidelines in prescribing a drug called Prostin to induce the labour. A midwife then failed to carry out the assessment of Heather's and the baby's condition properly before she administered Prostin. Soon after it was applied, Heather experienced intense abdominal pain.  Prostin caused the onset of uterine hyperstimulation, with powerful, frequent and overlapping contractions, which caused Heather to experience very intense abdominal pain and caused stress to the baby.

Twice the recommended dose of gel was used by a midwife in circumstances when, if she had carried out the pre-application assessment correctly, the drug should not have been used.  The drug was prescribed wrongly by the doctor, despite the hospital's guidelines on its use being rewritten following a similar tragedy at the same hospital in 2001.

Failure to monitor heart rate

This error was then compounded by the midwives' failure to read the CTG monitoring of the baby's heart rate properly. A midwife left Heather and Iain alone, telling Iain to watch the CTG trace himself and call her if the fetal heart rate dropped.  Each time Iain pointed out a dip in the heart rate to the midwife he was ignored, or made to feel he was being too fussy.  At the inquest the jury heart that the CTG trace had shown that the baby's condition was deteriorating and that action was needed.  An obstetrician from the Trust told the inquest that if the midwife had called for help when it was clear from the CTG trace that she should have done, Riley would have survived.

As it was, he was eventually delivered in very poor condition.  Although the paediatricians did what they could to help him it was no use: his injuries were too severe and he died.

Midwives rude and dismissive

As well as the neglect in carrying out their duties the jury also heard evidence that the midwives were rude, telling Heather that she was a 'silly girl' and that she 'didn't deserve the baby'. They were dismissive of Heather's pain and refused to call a doctor to see her, despite the couple pleading for them to do so.

Failure to follow hospital guidelines

During the coroner's inquiry evidence of a baby dying in very similar circumstances at the same hospital in 2001 emerged.  After that death the hospital carried out an inquiry, made recommendations and issued guidelines, including those relating to the use of Prostin.  After Riley's death the hospital carried out an inquiry and it became clear that the midwives and doctor involved with Heather and Riley's care had ignored, or were not aware of those guidelines.

Sally Jean comments:
" This is not the first case we know of in which a hospital Trust has carried out an investigation following a serious incident, made recommendations and issued guidelines to staff to prevent a recurrence, only for this to happen.  The Chief Medical Officer recently said that the NHS is an organisation with a memory.  Sadly, it would appear that what the staff of the Royal Free Hospital NHS Trust had learned from the death in 2001 had been forgotten by the time Riley was born."

For more information please contact Sally Jean Nicholes on 020 7650 1200.

Information was correct at time of publishing. See terms and conditions for further details.

Information was correct at time of publishing. See terms and conditions for further details.

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Clinical negligence

Who worked on this case

  • Sally Jean Nicholes
  • 020 7650 1281

  • Specialist Area