Louie Neil Johnston · Prevention of Future Deaths report

On 1st May 2020, I commenced an investigation into the death of Louie Neil Johnston, aged 1 week. The investigation concluded at the end of the inquest on 6th October 2021. The conclusion of the inquest was that Louie died from;

1a Diffuse Hypoxic/Ischaemic Encephalopathy
1b Acute chorioamnionitis with fetal inflammatory response
1c Ascending maternal genital tract infection

A narrative conclusion was arrived at.

Louie Neil Johnston died in hospital on 28th April 2020 as the result of diffuse hypoxic ischaemic encephalopathy, a condition caused by an inadequate supply of oxygen to the brain during his delivery on 17th April 2020. Avoidable delays in that delivery caused or contributed to his death.

Factors that produced the delay included:

1. Disregard of part of a cardiotocography (CTG) trace that monitors uterine activity, which led to uterine hyper-stimulation not being considered as the cause for a drop in the baby's heart rate,
2. A prolonged attempt to deliver using a ventouse cup,
3. A sequential decision to proceed to a forceps delivery after the ventouse cup delivery failed, instead of an immediate category 1 caesarean section.

1. CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery. This meant that a graphic representation of the CTG trace was not clearly visible at all times. Instead, midwifery staff were required to crouch down and record numeric data from the CTG displayed on a small LED screen. The Trust identified this as counter-productive and raised the issue with the manufacturer of the system. To date, the system has not been updated.

2. A review of staff training records indicated that an obstetric registrar involved in the delivery was not up to date with mandated annual CTG training. Additionally, the obstetric consultant had not completed annual training which required the session to be repeated following the death of Louie Johnston. Systems in place at the Trust did not ensure that all medical staff had completed requisite training.