Luna Lesko · Prevention of Future Deaths report

On 14th April 2011, an inquest was opened into the death of Luna Lesko, aged 26 days. The inquest concluded at Southwark Coroner’s Court on 16th August 2013. The conclusion of the inquest was a narrative (see section 4 below).

Baby Luna Lesko died at University Lewisham Hospital at 16.40 on 20th March 2011, after discontinuing intensive care, due to unsurvivable brain damage. Her mother was 41+4 weeks pregnant on 22nd February, became fully dilated at 14.30, with meconium liquor at 15.30. Syntocinon was begun at 19.00, increased at 19.48 and stopped at 20.20 as failure to progress with OP position. CTG remained normal. The baby was delivered by LSCS at 21.45 with Apgar 9 and normal blood gases.

She was put to the breast at 22.30 until 22.49. The paediatric doctor attending birth asked for meconium observations to be done as per Trust Protocol. Although there were records of two readings of pulse, reps and temperature, it was concluded that the full range of observations were not done by the attending midwife, in particular at around 23.15, when the baby was lying wrapped on the mother's chest. It was found that neither the prenatal events nor breast feeding contributed to death. Contributory causes were the position of the baby since there was at some time an occlusion of the airway and the failure to perform the required observations, in particular observation of skin colour. This failure amounted to neglect.

She was found collapsed with no respirations, pale and floppy at about 23.28, was resuscitated, required intubation and ventilation after 7 minutes and was transferred to NICU. There was a prolonged period of hypoxia from before she was found until intubation and persistent acidosis after, this being found to be a further contributory cause of the death. The resuscitation did not contribute to death. She had extensive investigations and treatments for all possible causes. The cause of the collapse was not found.

(1) There was a delay in securing a cardiotocograph (CTG) which she needed after she had meconium liquor at 15.30. ████████ was in the birthing suite and needed to access a labour ward room to have this foetal monitoring. The delay was due to the labour suite being very busy, but she was transferred and monitoring began at 17.02. I accepted expert evidence that what was best in the local context was not to site a CTG machine in the birthing centre, but to ensure access to the labour ward. Evidence was given that there is now another labour room. Whilst I did not conclude that there was now a risk to future babies from this arrangement, it establishes an on going increased capacity of the labour ward, which is relevant to the concern below.

(2) LSCS was required for the baby, due to lack of progression despite augmentation, adverse position and prolonged rupture of membranes with meconium. The decision was taken at 20.00 hours, but delivery was not possible until 21.40 hours, as theatres were busy. This delay of 1 hour 40 minutes for a category 2 section was 40 minutes outside the Trust’s own guidelines.

(3) The consultant obstetrician reported that this delay, which occurred out of hours, in a unit with over 4000 births per year was unacceptable. It worsens the potential impact, carrying a higher risk of brain damage or death of babies, if there were several emergencies at one time. Staff were reluctant to use the second out of hours (non obstetric) theatre as they cannot then respond to a category 1 emergency. My expert obstetric witness, ████████ of Kings College Hospital, gave an opinion that the out of hours theatre access created a real risk of preventable death, especially with the increasing rate of performing LSCS. He advised me that I should be concerned and bring the matter to the attention of the Trust.

(4) Whilst the Head of Midwifery reported management changes and compliance with CNST assessment, she did not provide assurance that the theatre capacity had been increased out of hours. Furthermore it was reported that the Trust is shortly to be disbanded and a new Trust is being formed by merger with another. This may lead to service configuration changes. She reported that the future obstetric services were under review.

(5) I concluded that a real risk existed that I should report to the Trust and the commissioning body, to ensure that it was fully appreciated and given appropriate priority in the service reconfiguration planning.