Theodore Riley Bradley · Prevention of Future Deaths report

On the 16th September 2023, I commenced an investigation into the death of Theodore Riley Bradley

The investigation concluded at the end of the inquest on the 5th July 2024

The conclusion of the inquest was a narrative as follows:

Theodore Bradley died from hypoxic ischaemic encephalopathy, caused by a placental abruption, secondary to sub clinical acute chorioamnionitis.
The abruption led to a major antepartum haemorrhage, which was not recognised as an obstetric emergency that required immediate assessment of maternal and foetal wellbeing.
Theo’s mother ████████ was not seen for 37 minutes on arrival at the Triage unit, at Kings Mill Hospital at 01.05 hours, when she was in pain and with significant vaginal bleeding,
Had she been seen on arrival as she should have been, Theo would have been delivered by an emergency Category 1 caesarean section, likely by 01.25, certainly by 01.35, instead of at 02.02 hours as occurred.

Had he been delivered at either of these earlier times, he would on balance have survived.
The delay in Triage assessment made a more than minimal, negligible or trivial contribution to Theos death.

Theo’s death was contributed to by neglect

Theo was born at 02.02 hours on 14.9.23 with no heart rate, and no breathing effort or movement. He had suffered a period of prolonged intra uterine hypoxia, due to a partial placental abruption.

His mother, ████████ reported vaginal bleeding at 41 plus weeks gestation, the severity of which was not recognised during the telephone Triage call, at 00.37 hours on 14.9.23.

On arrival at the triage unit at 01.05 on that day, ████████ was not seen as she should have been on arrival, nor thereafter until 00.42 hours, meaning there was a delay of some 37 minutes before she was seen.

Whilst delivery thereafter was achieved in 20 minutes, by this time Theo simply could not recover from the acute hypoxic injury caused by the continuing interruption to his blood and oxygen supply, caused by the abruption, evidenced at the time of delivery

Both the Trusts Maternity Triage policy and the Antepartum Haemorrhage policy were not followed

Detailed Findings as to how he came by his death are provided in a written Determination dated 5.7.24

1, The lack of prompt action when a woman presents with an antepartum haemorrhage (APH). This Inquest revealed a culture within the midwifery team of not acting promptly when there is vaginal bleeding in pregnancy. There was an assumption that there was a benign cause for bleeding, rather than assuming, until proven otherwise that there is a serious cause, such as an abruption, that may require immediate intervention.

Well established APH Trust guidance was not followed

I set out that difficulty in effectively managing APH is also an accepted issue, for the neighbouring NUH NHS Trust , who are currently reviewing their guidance, and approach to managing APH.

It is clearly a regional issue and may be a national one.

I am not reassured that necessary actions to address these serious issues identified are in place.