Peterborough hospital told to take action after death of seven day old baby Amelia

Peterborough City Hospital has been told to take action to prevent more deaths after a seven day old baby died.

Amelia Barbosa died in December 2020, a week after being born at the hospital.

Now Samantha Goward, Assistant Coroner for Cambridgeshire and Peterborough, has said she is concerned that unless the hospital takes action, more deaths could occur.

In a ‘prevention of future deaths report,’ Mrs Goward said: “Amelia’s mother had a routine pregnancy and was given a due date of 01 December 2020. She attended Peterborough City Hospital at around 1030 hours on 5 December 2020.”

She said that a decision to carry out a Caesarean section delivery was taken in the early hours of December 5.

In the report, she said: “Due to difficulties siting a spinal anaesthetic, and Amelia’s head being impacted, the time from decision to delivery was 83 minutes. Expert evidence confirmed that, on the balance of probabilities, Amelia suffered an acute hypoxic insult commencing around 10 minutes before her delivery and which was ongoing during resuscitation.

The report added: “The Midwife took cord blood gases but, as there was no blood in the clamped section of the cord, the blood was taken from a different part of the cord. I heard independent expert evidence from a Consultant Neonatologist that these are not likely to have been reliable as they were taken from close to the base of the placenta rather than the clamped section of cord.”

Making recommendations to the hospital, Mrs Goward said: “In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.

"While I heard evidence that there has been training for Midwives on how to take cord blood, and I was provided with a copy of a poster that was said to have been in use at the Trust for some time, in April 2023, over two years after this delivery, the Midwife gave evidence that she and her colleagues were of the opinion that it was appropriate to take a sample from anywhere in the cord, not just in the clamped area. The expert and the Trust’s own Head of Midwifery advised that this was not appropriate. It therefore does not appear that the learning has been passed on to all Trust Midwives and there is a risk that in future cases those treating the baby will be falsely reassured by normal cord pH results which may not be accurate.”

The inquest into baby Amelia’s death was held on May 17, with a conclusion recorded as: “Baby Amelia died as a result of an acute hypoxic injury in the period immediately before delivery, and which continued during resuscitation, leading to hypoxic ischaemic encephalopathy.”

North West Anglia NHS Foundation Trust have been given until July 15 this year to respond to the report, and set out a timetable for action to be taken.

The trust said they were unable to comment on the report