Serena Jane Nicholas · Prevention of Future Deaths report

On 5th September 2017 an investigation was commenced into the death of Serena Jane Nicholas, a new born baby. The investigation concluded at the end of the Inquest on Monday 11th November 2019. The conclusion of the Inquest was a narrative conclusion based upon the cause of death: 1(a) Intrauterine hypoxia, 1(b) Infant of a diabetic mother.

Serena Jane Nicholas died on Wednesday 30th August 2017 at 0010 hours at Leeds General Infirmary, shortly after she was born by a category 1 emergency Caesarean section performed at 2224 hours on 29th August 2017.

The pregnancy was complicated by virtue of (1) the mother’s type 1 diabetic condition which was poorly controlled and (2) a truncus arteriosus fetal heart abnormality identified on a 20 week scan. When the mother attended the maternity unit at the tertiary centre the evening before the planned C-section the following day, the fetal heart was found to be bradycardic, necessitating an immediate C-section. The baby was born in poor condition and died shortly afterwards.

(1) The antenatal surveillance was largely carried out in Hull where the mother lived. She was seen by a variety of clinicians and at a late stage by a community midwife, despite the recognition that this was a pregnancy accompanied by clear risk factors. The absence of identified consultants responsible for the oversight of mother and baby’s care in relation to diabetic and gynaecological aspects resulted in disjointed management.

(2) The tertiary centre where the C-section (and the subsequent open heart surgery envisaged) were to take place, were not aware that the baby had been inactive for some days before the planned C-section (because the mother had not reported this and had not had contact with clinicians since the clinical appointment with a community midwife on 24/08/17). In consequence, a serious adverse development went unheeded until symptoms crossed on the eve of the C-section. In view of the history of the pregnancy continuity of care and close monitoring of a high risk pregnancy led to a situation in which the desirability of advancing the C-section by say, a week, was not recognised.