O’Shea Medad Dover · Prevention of Future Deaths report

On the 27th May 2022 I opened an investigation touching on the death of O’Shea Medad Dover was 1 month old when he died. I opened an inquest on the 26th of September 2022, the inquest concluded on the 1st of February 2023. The conclusion of the inquest was the following narrative.

████████ was 30 weeks pregnant when she experienced abdominal pain and called emergency services. The call was wrongly categorised so paramedics arrived 44 minutes later than should have been the case. Midwifery advice was for the paramedics to bring ████████ to hospital because pre-term deliveries require full obstetric and neonatal support. They did not follow this advice for three reasons…

1. They thought ████████ was soon to deliver - a conclusion they’d be less likely to have reached had the call been correctly categorised and they’d been with her 44 minutes earlier;
2. Extrication from the property was challenging.
3. LAS guidance told them not to extricate if delivery is thought to be imminent.

Recognising the seriousness of the situation two midwives came to ████████. They deemed her presentation to be more in keeping with placental abruption than imminent delivery and assisted paramedics in extrication ████████ and taking her to hospital at 22.30. At 22.44, there was no foetal heart rate. At 23.04 O’Shea was delivered, resuscitation was started and caused a return of spontaneous circulation at 23.12. Given these things, it is likely O’Shea was subjected to acute severe hypoxia between 22.14 and 22.19. If the call to emergency services had been correctly categorised, ████████ would have probably been in hospital by 20.57, long enough for CTG monitoring to recognise foetal distress prior to the hypoxia at 22.14 which would have prompted emergency caesarian. Had this happened it’s likely O’Shea would have survived.

As set out in the above narrative. Since O’Shea’s death London Ambulance Service has added “JRCALC Plus” guidance stating where delivery is not progressing the patient should be conveyed to a hospital with obstetric support.

1. Consideration to be given for the national JRCALC guidance to include the London Ambulance Service’s JRCALC Plus recommendation that where delivery is not progressing the patient should be conveyed to an obstetrics unit;