Bethan Naomi Harris · Prevention of Future Deaths report

On the 20th February 2019 the Senior Coroner for the Coroner area of London (West) commenced an investigation into the death of Bethan Naomi Harris who was born on the 16th November 2018 at St George’s University Hospitals NHS Foundation Trust. The investigation concluded at the end of the Inquest on the 19th November 2019.

The conclusion of the inquest was that the medical cause of Bethan’s death was (1a) Hypoxic Ischaemic Encephalopathy

I recorded a narrative conclusion:

Bethan Naomi Harris died at Shooting Star Hospice on the 26th November 2018 after delivery at St George’s Hospital NHS Foundation Trust on the 16th November 2018. Her mother, ████████ pregnancy had been uneventful. After admission to labour ward labour progressed very quickly indeed and she sustained severe brain injury during delivery. Despite best efforts by the Neonatal team she succumbed to her injuries.

1. ████████ was 41 weeks + pregnant when she went into labour at St George’s University Hospitals Foundation NHS Trust.

2. She progressed through labour very rapidly – unusually so for a first time mother to be.

3. After she was moved to room four and at around 0450 to 0500 her unbroken membranes possibly containing meconium were visible to ████████ and she drew this to ████████ attention and I find that she did make the suggestion that CTG monitoring be undertaken.

4. For whatever reason the CTG was not placed. I find it was incumbent on MW Dunbar as the more senior midwife present – she was the Triage Midwife – to insist on the placing of the CTG.

5. Correct management of descent of membranes with liquor staining in a post dates woman progressing quickly in her first delivery was to rupture the membranes. Indeed ████████ told me that had she known there was meconium in the liquor she would have ruptured the membranes and started the CTG monitoring.

6. In my view it is likely ████████ did know and did not act at the time for reasons unknown

7. Had the membranes been ruptured it is more likely than not that delivery would have been expedited and the situation with the plunging fetal heart rate obviated. I consider it more likely than not that Bethan would then have been born in better condition. Unfortunately I cannot say on the balance of probabilities even with this intervention that Bethan would more likely have survived longer term.

(1) The Inquest was held one year after Bethan Naomi Harris's death. During the course of the oral evidence it emerged that several, in my mind important, learning issues had not been addressed.

(2) There were issues relating to handover of patients to midwives and at the time of Inquest there had been no further specific training in relation to handover. Indeed it was stated that the process in place at the time of Bethan’s delivery still pertained without alteration. This represented a risk to patients.

(3) At the time of Inquest a team debrief, which I consider to be a source of learning to reduce the risk of serious incident in future was still outstanding.

(4) There was little evidence from the oral evidence given that any effective reflection, reflective discussions or learning had taken place subsequent to Bethan’s birth and then death. I consider it important that organisations seek to ensure individual and collective reflection to seek to avoid repetition. The evidence for this, one year on, was lacking.