Dayani Chauhan-Ahmed · Prevention of Future Deaths report

On 4th October 2013 I commenced an investigation into the death of Dayani Chauhan-Ahmed, 1 day old. The investigation concluded at the end of the inquest on 25 June 2014. The conclusion of the inquest was

“Mrs Chauhan-Ahmed was admitted in labour to Leicester General Hospital for the anticipated and planned delivery of her first baby. She did not receive adequate medical attention due to other concurrent emergencies. Dayani was delivered naturally in very poor condition and died from the consequences of prolonged labour. Her death was due to natural causes, contributed to by neglect.”

This was a low risk term (41 weeks) delivery for midwifery care. There was a prolonged second stage of labour, augmented with syntocinon. On the evening in question, additional midwifery assistance would have led to earlier commencement of the role of the syntocinon infusion, and allowed the midwife co-ordinator to continue with her role rather than carry out other clinical tasks.
Despite plans for further medical reviews, and requests for medical attendance, these did not happen and Mrs Chauhan-Ahmed eventually progressed to a natural birth after a second stage exceeding 5.5 hours.

This management fell well outside NICE and Trust guidelines and protocols.

Dayani was born in poor condition and despite intensive care the situation was soon considered to be futile and care was withdrawn with parental consent. The cause of death was considered due to prolonged labour, peripartum asphyxiation and severe hypoxic ischaemic encephalopathy.

(1) Notwithstanding the presence of all material times of a Consultant on the delivery ward, the length of time of the second stage of this labour did not appear to be communicated effectively to either the Consultant or the midwife co-ordinator, due to other events occurring that night. The “white board” system of communication was ineffective as neither of the above had an opportunity to look at this. The Trust should consider a program for communication on such occasions that is effective and may include slight of the CTG trace, where applicable, by the most senior clinician available.

(2)The Trust escalation policy has been changed since this death, but there seemed to be uncertainty, on how well this was known by all relevant midwifery and medical staff, and in particular ensuring knowledge for new staff. Knowledge of the procedures, and adherence to the time limits set out for escalation are key to the effectiveness and the Trust should consider further how this can be robustly incorporated into working practice.

(3) The Trust should consider arranging for additional midwifery and medical availability to assist during times of extreme demand on the service. The current informal “SOS” system for midwifery attendance, while promising, should be further explored and confirmed in Trust policy if considered to be effective.