Maia Hazel Ann Strachan · Prevention of Future Deaths report

On 10 July 2017 I commenced an investigation into the death Maia Hazel Ann Strachan born on 6 July 2017 and died on the 7 July 2017.

The investigation concluded at the end of the inquest on 17 April 2019.

The conclusion of the inquest was:

Medical Cause of death:

1a. Hypoxic Ischaemic Encephalopathy
1b. Complication of Shoulder Dystocia secondary to Macrosomia
2. Maternal Diabetes

Narrative Conclusion:

Died due to complications of shoulder dystocia to which missed opportunities to reduce the risks of and diagnose severe foetal macrosomia contributed.

Maia Hazel Ann Strachan was born on the 6 July 2017.

Her mother suffered from Diabetes and High Body Mass Index. Her Diabetes was uncontrolled before the pregnancy and in its early stages.

This increased the risk of Foetal Macrosomia and consequently the risks of delivery.

An ultrasound scan was performed on the 21 June 2017.

The images were suboptimal, an incorrect formula used to calculate foetal weight and femur length inaccurate. This resulted in an underestimation of foetal weight and a missed opportunity to plan Maia’s delivery by Caesarean Section.

A plan for induction of labour was implemented on the 4 July 2017.

At approximately 10am on the 6 July 2017, an opportunity was missed for delivery by Caesarean Section at mother's request. Maia’s delivery was thereafter complicated by Shoulder Dystocia and prolonged attempts to deliver her which led to Hypoxic Ischaemic Encephalopathy and her death within the Royal Victoria Infirmary, Newcastle upon Tyne on 7 July 2017

Maia was severely Macrosomic weighing 5.1 kilograms at birth.

On the balance of probabilities, Maia would have survived if delivered by Caesarean Section.

(1) The ability to store sequential scan data specific to each patient and provide alerts to the Sonographer.

This would facilitate comparison and prompt further investigation potentially altering a patient’s care plan and outcome.

The Trust’s plan to procure software to facilitate the above should be urgently implemented.

(2) A system of joint obstetric and diabetic care operates without the facility for clinicians to access patients’ obstetric and diabetic records whether manually or electronically.

Accessibility is essential to inform clinical decisions and should be urgently addressed

(3) Joint Decision Making: -

Provision of advice and explanation of the risks of pregnancy and the risks/benefits of vaginal delivery or by Caesarean Section are essential to ensure informed decision making.

The Trust should draft and implement a clear and comprehensive Local Joint Decision Making Policy/Protocol.

(4) Foetal Scalp Electrode:
The use of Foetal Scalp Electrodes (FSE) provide critical information in respect of foetal distress and the time implications thereof.

The Trust should draft and implement a clear and comprehensive Local Policy/Protocol for FSE use.

(5) Suboptimal Documentation:
The Trust should implement a robust training and audit plan to address the risks of this occurring in the future.

(6) The Findings and Conclusions of ████████ (Independent Expert Witness):

A redacted copy of ████████ report and conclusions should be circulated to all obstetrics and gynaecology staff (both nursing and medical) and all midwives.