Kobi David WRIGHT · Prevention of Future Deaths report

On 14/08/2019 I commenced an investigation into the death of Kobi David WRIGHT aged Less than 1 day. The investigation concluded at the end of the inquest on 9 July 2020. The medical cause of death was:
1a) Preterm Stillbirth
1b) Complicated Instrumental and Caesarean Delivery
1c) -
2 Prematurity
The conclusion of the inquest was: Stillbirth.

Maternal membranes ruptured on 1 March 2019 and there was admission to James Paget University Hospital where monitoring was undertaken. On 3 March 2019 examination and reassessment took place. Following an examination at 13:30 and again at 13:50, forceps delivery was attempted. Kobi’s head was delivered vaginally but delivery of his body was unsuccessful. An attempt was made to deliver Kobi by caesarean section which was initially unsuccessful, and delivery by forceps re-attempted. This was not successful and delivery by caesarean section was again attempted. Kobi was eventually delivered at 15:28 hours. He showed no signs of life and after attempts at resuscitation and assessment Kobi was declared dead.

1. D ████████ evidence was that the cervix was almost fully dilated at 12:30 and 13:50 examinations at which point it could be “pushed easily”, which was not supported by midwife’s evidence of examination at 13:30 (8cm) nor of what transpired at attempted delivery, namely that cervix “retracted” to 6 to 7cm;
2. Dr ████████ evidence was that during a telephone conversation at 13:57 he did not express concern about the CTG reading and did not give this as the reason to proceed to delivery of Kobi. This was in conflict with the evidence of Dr ████████ Consultant Obstetrician/Gynaecologist and to his first statement 16.7.2018 para 6.
3. Dr ████████ evidence at the inquest that he expressed concern about Kobi’s mother being pre-term, high risk with prolonged rupture of membranes was not contained in his first statement nor in his record of the conversation. In any event the evidence of Ms ████████ and the expert Mr ████████ who gave evidence was that these would not be reasons in themselves to proceed to an early delivery at that time.
4. Further ████████ second statement 21.4.2020, refers to some consideration being given to variable decelerations and variabilities contained in the CTG trace when making his decision to proceed to delivery at that time. It was accepted by Dr ████████ Ms ████████ consultant and Mr ████████ expert, that the CTG readings were within normal range and would not be a reason to proceed to delivery at that time. Their evidence was it would be appropriate in light of the full clinical picture and the CTG readings to “wait and see” how matters progressed.
5. Dr ████████ gave evidence that his arranging to take Kobi’s mother to theatre and prepare for delivery, and then carrying out a further vaginal examination at that time, would stand in for a later examination to see how matters were progressing. This was not regarded as good practice by the expert on the basis, it would be better to carry out a further examination after an hour, and then decide how to proceed with the delivery.
6. Dr ████████ did not accept the Consultant’s offer of assistance but regarded himself as fully competent to carry out the procedure.
7. Dr ████████ proceeded with a forceps delivery of the baby’s head. The body did not follow and the cervix “retracted” (which Dr ████████ had not encountered before. Nor had Mr ████████ the expert witness). Dr ████████ cut the cervix and rotated the head and tried unsuccessfully to deliver the shoulders through the incision. Mr ████████ expert said in evidence the baby’s head on its own should never be rotated due to the damage this can cause.
8. Dr ████████ instructed a midwife to replace the baby’s head.
9. Dr ████████ then attempted to deliver the baby via caesarean section, which was unsuccessful.
10. Ms ████████ then attended and arranged for the Paediatric Team to be called. She was eventually able to deliver the baby
11. There was a conflict in the evidence as to whether Ms ████████ applied both forceps blades. The evidence of Ms ████████ was preferred in that she was the one performing the procedure and would be best placed to know what she was doing and she had throughout been a good and competent witness.
12. There was no evidence that Dr ████████ had undergone training in emergency obstetrics in the recent period prior 3 March 2019. Dr ████████ has undergone training since 3 March 2019 but at the instigation of North Devon District Hospital.