infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf) · Prevention of Future Deaths report

On the 11th February 2015 I commenced an investigation into the death of infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf).

On the 5th July 2013, the deceased’s mother was admitted for planned induction of post-term labour. At around 15:50 hours, a CTG demonstrated anomalies. The midwife sought a medical review. The initial CTG demonstrated recovery however by 20:50 hours, a further trace showed evidence of a more marked anomaly. The significance of this CTG was not fully recognised.

At 22:00 hours doctors made the decision to proceed to emergency caesarean section. As a consequence, the deceased’s mother was transferred to the labour ward at around 22:20. At 22:48 a further examination was carried out by a doctor during the course of which an artificial rupture of membranes was performed. Tenacious, fresh meconium was noted within the liquor. The deceased’s mother was transferred to theatre at 22:53 with baby being delivered in a very poor condition at around 23:42. Neonatal resuscitation was commenced immediately and thereafter, the deceased was transferred to the NICU. Over the course of the next few days, tests showed that the deceased was suffering from electrocebral silence, meconium aspiration syndrome, seizures, hypoxic cardiomyopathy and presumed sepsis. The deceased’s condition continued to deteriorate and he died on the 19th July 2013 from hypoxic ischaemic encephalopathy due to or as a consequence of perinatal asphyxia.

During the course of the treatment and care provided, an official Interpreter was not summoned or utilised.

During the course of the inquest the following concerns were identified:

1. Whilst Pennine Acute Hospitals NHS Trust has now established its own local guidelines based upon recent research conducted in Bristol, there are no national guidelines on how to interpret and/or classify antenatal (as opposed to intra-partum) CTG tracings.

2. The dissemination, application and applicability of the Trust’s Interpreting Policy, by its staff, in force at the material time (with particular regard to the obtaining of informed consent).