Ivy Rebecca Morris · Prevention of Future Deaths report

On 6th May 2016 I commenced an investigation into the death of Ivy Rebecca Morris aged 4 months. The investigation concluded at the end of the inquest on 12th October 2016. The conclusion of the inquest was Ivy Morris died from natural causes where death would have been prevented had appropriate monitoring taken place in the second stage of labour. The second stage of labour was delayed which added to the period of hypoxia and the severity of Ivy's hypoxic ischaemic brain injury at birth. As a result of her avoidable injuries, Ivy was vulnerable to bronchopneumonia, a condition from which she suffered in the months following her birth. On 3 May 2016 Ivy collapsed at home following an episode of bronchopneumonia and did not recover.

Ivy was born at the Princess Royal Hospital, Telford on the 15th December 2015 following complications at birth Ivy was born with limiting medical needs including severe perinatal hypoxic ischaemic brain damage. Ivy had a prolonged stay in hospital following her birth and on discharge home she required her feeds through a nasogastric tube. On the 3rd May 2016 Ivy was at home at ████████ being cared for by her father ████████ During her feed ████████ witnessed Ivy becoming unresponsive. He called for an ambulance and commenced resuscitation until the arrival of the ambulance. Resuscitation was continued by the paramedics until arrival at the Royal Shrewsbury Hospital where Ivy was pronounced dead.

(1) Foetal heart monitoring.
Ivy's foetal heart rate ought to have been monitored and was not monitored. In the second stage of labour the maternal heart rate was recorded on the external CTG machine for the majority of (if not all) the time when the intent was to monitor the foetal heart rate. The confounding factor was the similarity of the heart rates at the commencement of the second stage. There were opportunities and methodologies available to resolve this issue that were not taken. There was evidence of potential error of this kind in the interpretation of CTG traces being a known phenomenon.

(2) Failure to follow midwifery guidelines.
a. To confirm assessment of the CTG using the agreed assessment tool.
b. The need to request an obstetric review after 1 hour of active pushing.
c. The need to request an obstetric review for maternal tachycardia.

(3) Episiotomy.
Infiltration took place which could have led to an episiotomy and delivery within 10 minutes. There was unresolved evidence as to whether an episiotomy was a planned event or a contingency which did not arise. There was though evidence that the midwife who performed the infiltration had not performed an episiotomy since qualification and wished to have support and supervision should one become necessary. Whilst such support and supervision may have been available in this case, in other this could lead to delay.