Lucy Hannah Rose Bailey · Prevention of Future Deaths report

On the morning of the 16th September 2010 ████████ Lucy’s mother, started her contractions whilst she was at home. An ambulance was called and a paramedic and his colleague who was a qualified technician, arrived at 07.39. They in turn summoned a midwife.

The labour continued and her waters broke. A second ambulance crew arrived staffed by Emergency Care Assistants. The paramedic put ████████ into the McRoberts position and the baby’s head was born but her body did not follow. ████████ was then put on all fours, but the birth did not continue. At no time was there any gentle traction to the baby’s head by the paramedic or any internal manipulation of the baby whilst she was in ████████████████

The midwife arrived at about 8.10, by which time the baby’s head had been born for several minutes. The midwife put ████████ back into the McRoberts position and with some encouragement and internal and external manipulation Lucy was born at 08.14. It appeared to the midwife that Lucy’s shoulders were in the transverse position, and that her shoulders semi-rotated as the baby was expelled.

Lucy was not breathing, and CPR was applied. Lucy was placed in the ambulance to be taken to hospital and a heart rhythm and spontaneous circulation was recorded at 08.56.

However at hospital it was clear that Lucy had been starved of oxygen and had suffered irreparable brain damage. She died the following day, on the 17th September 2010.

The evidence given at the Inquest by the paramedic concerned and by an expert in paramedic training, was that shoulder dystocia was a known hazard, and that the training guidelines specifically provided for the paramedic to put the mother into different birthing positions to try to assist a natural birth. The evidence was that the paramedic training process prohibited the paramedic from providing traction to the baby’s head, or providing any internal or external manipulation of the baby whilst in the mother’s vagina.

The standard training reference documents on paramedic training are provided by the Institute of Health Care Development (IHCD) training manual, and the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines.

████████████ Consultant in Obstetrics and Fetal Maternal Medicine, was instructed by HM Coroner to provide an independent report. In his evidence at the Inquest he felt it likely that the baby was large, and that the birth was hindered by soft tissue dystocia rather than shoulder dystocia. He felt that had the paramedic been in a position to provide gentle hands on traction of the baby’s head or gentle internal manipulation of the baby whilst in ████████████ then Lucy may have been born without injury.

He went on to suggest that it was appropriate for paramedic training to provide for hands on assistance in giving gentle traction to the baby’s head and that the risk to the baby in being injured was likely to be less than the risk of devastating oxygen starvation if such assistance was not provided.

That consideration should be given to amend the training manuals and guidelines to provide for the training of paramedics to assist a birth by providing gentle traction to the baby’s head and/or gentle internal manipulation of the baby whilst in the mothers vagina.