A string of failures by ‘wholly incompetent’ hospital staff caused the death of a newborn baby girl, an inquest has found.
Eight separate shortcomings were identified by a coroner over the death of Ida Lock – as he attacked the ‘callous and inhumane’ treatment of the infant’s family.
Coroner James Adeley made a finding of neglect after recording a narrative verdict and said: ‘Ida’s death and subsequent investigation is a damning indictment of an ineffective, dysfunctional and callous system that has failed this family at every opportunity presented to it.’
Ida Lock was born at the Royal Lancaster Hospital on November 15, 2019 but died after midwives failed to react to her falling heart beat while mother Sarah Robinson was in a birthing pool.
The newborn baby suffered hypoxic brain damage caused by oxygen starvation during her difficult birth and the ‘wholly incompetent’ attempts at resuscitation by midwives.
A 19-day inquest at Preston heard that Ida from Morecambe, Lancashire, died a week after she was born, having been transferred to the Royal Preston Hospital.
Ms Robinson, 42, and Ida’s father Ryan Lock listened intently as Mr Adeley listed the shortcomings in their daughter’s care:
Mr Adeley said baby Ida could have survived if she had been born just ‘six and a half minutes earlier’, prior to the failings occurring.
He made a Prevention of Further Deaths order to be sent to the Secretary of State for Health after a hard-hitting analysis of the hospital’s handling of Ida’s birth.
Mr Lock, a teacher, told how the conclusion came after a near six-year battle for the truth which ‘has changed me as a person’.
He said: ‘It’s a sheer test of endurance that no parent should endure… It’s a fight for justice, in my eyes.
‘Words truly cannot express how heartbreaking it was to lose Ida and there is not a single moment when we do not think about her and what she may have become.
‘The coroner found there was a litany of lamentable failures which led to the death of our beautiful baby girl.
‘There has been systemic failings at the Trust. Why did we have to endure this? As a family we have only wanted answers as to what happened to Ida.’
He added: ‘We still do not know why the Trust were not open, why they were not candid. Hopefully Ida is no longer a hospital number but her name will be used to implement change and help parents understand what happened to their child.’
University Hospitals of Morecambe Bay Trust, which runs Royal Lancaster, was previously criticised in a hard-hitting report in 2015 for ‘a major failure at every level in maternity and neo natal services’ following the deaths of 11 babies and one mother.
In 2020, a report by the Independent Healthcare Safety Investigation Branch identified numerous failings in the care of Ida which contributed to her death.
Mr Adeley said there had been ‘a gross failure to provide basic medical care to a person in a dependent position’ during Ida’s birth.
The coroner said: ‘Ida was a normal child whose death was caused by a lack of oxygen during her delivery that occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress.
‘I find that the dilatory approach of the midwives to the lowered foetal heart rate of 100 bpm, which had been present for an uncertain duration and was sustained over two minutes of listening, was a failing to appreciate a rapidly developing obstetric emergency, and would be sufficient to constitute a gross failure resulting in Ida’s death.’
The coroner said that Ida had died from hypoxic brain damage caused by the ‘wholly ineffectual’ attempts at resuscitation in the first three minutes of her life.
In his narrative conclusion, Mr Adeley criticised the Trust as ‘inhumane’ for failing to respond to a letter from Ida’s parents asking for an explanation of how their daughter died.
He said that the Trust had shown ‘a lack of compassion and honesty’ and had adopted a ‘defensive position’ amid an ‘endemic’ culture.
Mr Lock added: ‘The answers today will not bring our daughter back but hopefully will stop another family going through what our family has been through.
‘This should not be a test of endurance for bereaved and bewildered parents to work out what happened to their child. Hopefully today we can start healing and we can grieve differently.’
Tabetha Darmon, Chief Nursing Officer, University Hospitals of Morecambe Bay NHS Foundation Trust, said: ‘Losing a child is tragic and our heartfelt condolences go out to Ida’s parents, family and loved ones. We are truly sorry for the distress we have caused.
‘We accept that we failed Ida and her family and if we had done some things differently and sooner, Ida would still be here today.
‘We take the conclusions from the Coroner very seriously and have made a number of the improvements identified during the inquest. We are carefully reviewing the learning identified to ensure that we do everything we can to prevent this from happening to another family.’