Impacted Fetal Head During Labour: Maternity Negligence23 Jun 2021 | Stephanie Prior
According to the World Health Organisation, labour is considered obstructed when the fetus cannot progress along the birth canal, despite strong uterine contractions. The obstruction can be alleviated either by caesarean section or by instrumental delivery, such as with forceps. Unfortunately, worldwide, neglected obstructed labour is a major cause of both maternal and newborn morbidity and mortality.
Currently, there are no UK or International guidelines on how to manage an impacted fetal head: there are many potential techniques, but no single method has been deemed superior.
Is a fractured skull in the neonate evidence of obstetric negligence?
There is still an ongoing debate as to whether a fractured skull discovered in the neonate after a caesarean section is evidence of negligence. The British Journal of Obstetrics and Gynaecology published an article by Philip J Steer on 25 January 2016 which reviewed 4 fetal deaths over 3 years from the push technique. The alternative technique is the pull method (ie reverse breech) and apparently, this is faster, the article says this resulted in less maternal morbidity than push from below (ie push technique) but there is less difference in birth trauma. These 4 perinatal deaths were associated with a skull fracture and caesarean section when the mother was fully dilated (10cm), and there had been no prior attempt at instrumental delivery. In each case, there were apparently repeated attempts by the Obstetrician to deliver the head by passing the obstetrician’s hands from the uterus down past the fetal head. This was to enable the Obstetrician’s hands to get underneath the baby’s head and pull it up. There was also pressure from an assistant’s hand in the woman’s vagina.
This article concludes;
‘These cases suggest that it may be best to avoid further compressing an impacted fetal head by pushing a hand past it while also applying force from below. However, such anecdotal evidence does not necessarily mean that on the balance of probability the injury would have been avoided if the pull method had been employed.’
2020 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
A recent BBC news article raised the issue of fetal head injury during labour. It cited the story of newborn Clay Wankiewicz who died from multiple skull fractures, seemingly caused by a poorly performed labour and forceps delivery at the Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust.
Beth Wankiewicz carried Clay to term and her pregnancy was deemed low risk. In July 2020, Beth went into labour around her due date. After 24 hours, the labour was not progressing, so an inexperienced junior doctor made two attempts to deliver Clay with forceps, as no senior doctor was available on site. Finally, Clay was pushed back into the womb so that a caesarian section could be performed. Tragically, Clay was declared dead 20 minutes after his birth. The staff told Clay’s parents that he had been stillborn. It is notable that stillbirths are not reported to the coroner for post-mortem or investigation.
A midwife later told the couple that Clay had in fact been born with a heartbeat and therefore could not be deemed stillborn. Eventually, Clay was referred to the coroner for a post-mortem, which indicated that he had died from multiple skull fractures.
It is unsurprising that his family believe that Clay was initially deemed stillborn in order to avoid the scrutiny that comes with a coroner’s inquest.
2016 review of Doncaster and Bassetlaw Maternity Services
Unfortunately, the circumstances that led to Clay’s death had already been flagged as safety issues, as far back as 2016. A review of the Doncaster and Bassetlaw NHS Trust’s maternity services was conducted by the Royal College of Obstetricians and Gynecologists, and found serious patient safety concerns, including lack of appropriate leadership and consultant availability. The results of the review were never made public, despite being required to do so, following the 2015 Bill Kirkup Inquiry. Had the safety concerns been addressed at the time, perhaps Clay would be alive today.
The Bill Kirkup Inquiry
In 2015, the report of the Kirkup independent public inquiry into maternity and neonatal care provided by the Morecambe Bay NHS Foundation Trust was published. Kirkup found that in the Trust, between 2004 and 2013, there was a ‘serious failure of clinical care’ due to the dysfunctional unit providing substandard care by staff deficient inappropriate skills and knowledge. The failure was deemed to have resulted in the ‘tragic and unnecessary deaths of 11 babies and one mother.
The requirement to publish not enforced by law
Following the Kirkup review, the government determined that NHS trusts are required to publicly publish summaries of external reviews and share them with their regulatory body. However, there is no law to enforce this. This means that crucial patient safety reports are easily concealed if the results are unfavourable to the Trusts.
As already discussed, the 2016 review of the Doncaster and Bassetlaw NHS Trust’s maternity services by the Royal College of Obstetricians and Gynecologists was not made public. This concealment is not unusual. Indeed, a Panorama investigation into the matter, broadcast on the 19th May 2021 found that when care goes wrong, some Trusts keep critical reports hidden from both the regulator and the public.
Scandal after scandal: disregarding Kirkup recommendations
The Clay family’s case is not unusual, either in the failure of clinical care or in the cover-up of a previous critical review.
In 2017, in a Margate hospital, inexperienced junior doctors were left in charge of a labour that was failing to progress. They were required to perform an emergency caesarean section to deliver baby Harry, as no senior doctor was available for the procedure. His traumatic delivery and delayed resuscitation left newborn Harry with brain injuries due to lack of oxygen, and he soon died. Initially, Harry’s death was not reported to the coroner, but when it was finally referred, the inquest found that Harry’s death was ‘contributed to by neglect’ and his death deemed ‘wholly avoidable’.
As with the Doncaster and Bassetlaw Trust, a review into the Margate Trust’s maternity services had been commissioned 2 years previously. The report alerted the Trust to the risks inherent in the practice of forcing unqualified doctors to take responsibility for emergencies, due to lack of onsite consultant support.
It seems that across the UK, poor clinical practice is being identified but not addressed. This raises the question: what is the point of commissioning an expert review if the risks to patient safety are not acted upon?
At Osbornes Law, we act for many clients who do not speak English as their first language. This in our experience, has created significant issues for pregnant women, under the care of the obstetric team at their local hospital. We are currently acting for several women who have each delivered babies with catastrophic brain injury; many women who have delivered babies who were stillborn and also the family of a young mother who died post caesarean section. The common thread in all of these cases is that communication was poor and the urgency of each situation was not appreciated by the medical and nursing staff caring for the mother due to the significant language barriers.
The prosecution may focus the minds of Trust leaders
Perhaps the only way to ensure that patient safety concerns are appropriately addressed is through the application of the Law. The Margate hospital involved in Harry’s death is to be prosecuted. Accused of exposing Harry and his mother to ‘significant risk of avoidable harm’ in ‘terrifying’ and ‘chaotic’ circumstances’, the Trust is facing 2 charges under Regulation 12 of the Health and Social Care Act 2008, for failing to provide safe care and treatment. This is thought to be the first time that the Care Quality Commission has brought a prosecution for clinical care safety breaches.
It is right that investigations into patient safety concerns should be carried out by independent professional bodies such as the Royal College of Obstetricians and Gynecologists. However, unless the concerns are acted upon and changes made, the same mistakes will be repeated. By holding to account the Trust within a legal framework, rather than scapegoating nurses and doctors through their professional bodies, this groundbreaking prosecution may represent a sea change in how senior managers and CEOs take responsibility for the safety of patients under their care.
Our team have experience in dealing with cases of this nature so if you would like to discuss your issue further please call 0207 485 8811 or complete an online enquiry form.
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