Casey Paul GARRETT · Prevention of Future Deaths report

On 12th September 2014 I commenced an Investigation into the death of Casey Paul GARRETT. The Investigation concluded at the end of the inquest on 21st July 2015. The Conclusion of the Inquest was a Narrative Conclusion: “Casey Garrett was born on 10th September 2014. Prior to his delivery at Bedford Hospital there were a number of failures to recognise that his condition was deteriorating and there was failure to escalate the level of care so as to expedite his delivery. These failures resulted in a lost opportunity to deliver him earlier and avoid his death. He died on the 11th September 2014 at 07:10 hours from Perinatal Asphyxia”.

Baby Casey Garrett was born with a zero APGAR score at birth - gestation 38+6. Full CPR was commenced, but his APGAR score remained at zero at 1, 5 and 10 minute intervals after delivery. A heart beat was first noted at 27 minutes of age, after intensive CPR. He was then transferred to the Neonatal Intensive Care Unit for ongoing management. There were serious failings with regard to midwifery care in that:

1. The original Cardiotocography (CTG) was discontinued despite being non-reassuring.
2. There was a failure to carry out intermittent auscultation in accordance with the Trust Policy.
3. When the labour became abnormal at 22.00 hours there was a failure to call for an obstetric review by the doctor on call.
4. There was a failure to recognise that the CTG started at 10.12 hours was recording the maternal pulse.
5. Had the medical staff been alerted to the baby’s deteriorating condition, and the deviation from the norm, an instrumental delivery would have been performed by 10.30 hours
6. If delivery had been achieved 20-30 minutes earlier Baby Garrett would have survived.

My concern was regarding the clinical learning environment, in that a Student Midwife was working with a Midwife and witnessed/carried out entirely inappropriate midwifery care which led to this infant’s death, including insufficient fetal monitoring, mis-interpretation of a CTG trace and the failure to escalate the level of care when there was a “deviation from the norm”.

1. The incident raises questions about the suitability of Bedford Hospital NHS Trust being used as a clinical learning environment for Student Midwives – this needs an urgent review in the interests of safety of mothers and babies to avoid similar deaths in the future.