Mojeri Adeleye · Prevention of Future Deaths report

On 10 March 2022 I commenced an investigation into the death of Mojeri Adeleye born on 1 March 2022. The investigation concluded at the end of the inquest on 10 January 2023. The conclusion of the inquest was:-

Natural Causes

The medical cause of death was:

1a: Extreme Prematurity
1b: Pre labour premature rupture of membranes

Mojeri's mother was supported throughout most of her pregnancy at her local hospital in Grimsby. Due to concerns and the premature rupture of membranes her care was transferred to the Jessops Wing in Sheffield. Unfortunately, Mojeri's mothers referral notes in respect of her expected due date were not correct. Despite this being brought to the attention of staff multiple times, the staff at the Jessops Wing refused to accept that Mojeri's mother was providing them with the correct information.

Mojeri's mother went into labour and due to the policy, guided by national practice, no life saving support was offered to Mojeri because he was under 22 weeks gestation. This was not the subject of discussion with Mojeri's parents due to his gestational age. Unfortunately, the information which the hospital held about Mojeri's gestational age was incorrect and at the time of the premature labour he was just over the 22 weeks gestation mark.

I was told in evidence that the single biggest feature in Mojeri's death was the much earlier premature rupture of membranes at 17 weeks gestation and that even if the correct gestational age had been known there would not have been different treatment offered. I was also told in evidence that conversations about whether exceptional measures will be taken to support premature babies take place in the 22nd week of pregnancy rather than in the 21st.

The lack of regard towards Mojeri's mothers knowledge of her own pregnancy and the estimated due date for Mojeri.

The lack of discussion with Mojeri's parents about the possible measures that could be taken in the event of premature labour before the 22 week mark.