Isla Peyton LORD · Prevention of Future Deaths report

On 19 November 2012 I commenced an Investigation into the death of Isla Peyton LORD, aged 4 days . The Investigation concluded at the end of the inquest on 28 January 2016. The Conclusion of the Inquest was a ‘Narrative Conclusion’ that “… Isla Peyton LORD was born on 4 November 2012 at the Princess Alexandra Hospital in Harlow. Following delivery she suffered an inexplicable immediate post-natal collapse; initial attempts at resuscitation were unsuccessful and she suffered a hypoxic ischaemic brain injury. She was transferred to the Luton and Dunstable Hospital where she died on 8 November 2012.

Isla was born at Harlow Hospital on the 4th November 2012. During pregnancy, an antenatal scan detected the right leg bent above the knee. There were also concerns over an enlarged heart chamber. She was born by Emergency C Section; she cried upon delivery, however, then collapsed. There was a prolonged period of resuscitation and she was found to have a hypoxic brain injury. She was subsequently transferred to the Luton and Dunstable Hospital at 06.00 hours on the 5th November 2012, where she was ventilated. Discussions then took place with Isla's parents when a decision was made to withdraw treatment. She sadly died on the 8th November 2012.

1. During the course of the evidence it became apparent that once the possibility of heart anomalies was identified at University College Hospital in London (UCLH), there was no liaison between Princess Alexandra Hospital in Harlow and UCLH as to the plan for the delivery of the baby. It was simply agreed that UCLH were content for her to be delivered at the local hospital with a referral being made to Great Ormond Street Hospital after delivery. In order to prevent deaths in the future there needs to be a review of the system that exists between the tertiary hospitals and Princess Alexandra Hospital as to how to formulate an Agreed Delivery Plan for both mother and baby.