Frederick Joseph Terry · Prevention of Future Deaths report

On 16 November 2019 I commenced an investigation into the death of baby Frederick Joseph Terry. I decided to make this report during the investigation stage prior to reopening the inquest touching upon baby Terry’s death. On 4 September 2020 I reopened the inquest and I heard evidence relating to the specific issue as to whether or not baby Freddie was stillborn. I found as a fact that baby Freddie was stillborn, I called no further evidence and I concluded in box 4 on the Record of Inquest that Frederick Joseph Terry was stillborn.

Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on 16 November 2019 and death was confirmed after 40 minutes of resuscitation attempts. The cause of death at post mortem examination has been given as:-

1a) hypovolaemic shock
1b) skull fracture and scalp laceration and haemorrhage
1c) birth trauma

The evidence showed that baby Freddie’s very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby.

Independent expert opinion has drawn attention to the following areas of concern

• Lack of risk assessment leading to the options available to mothers as to delivery
• Forceps delivery was attempted without recognising an occipito-posterior position. More training in this respect is required and the use of cans developed.
• The injuries imply an excessive degree of force in the application of the forceps and the traction
• Concerns about the engagement and induction of locum staff and management of staff levels on the maternity ward
• The need for a bleep in the neonatal unit
• Accuracy of record keeping
• Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre
• Training and procedures in respect of how communications with the family should be carried out. This should cover the duty of candour.
• Availability and suitability of resuscitation equipment and procedures on the maternity ward. The Trust’s Neonatal Resuscitation Policy may need to be revisited
• The Trust’s Action Plan must be rigorously carried out
• It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery. Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In March 2019, HM Government issued a Consultation on coronial investigations of stillbirths. It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.