Devastated Cambridgeshire couple call for lessons to be learnt after birthing delay leads to death of five-day old baby

A Cambridgeshire couple are calling for lessons to be learned after their five-day-old daughter Scarlett died from brain damage following a nine-hour delay in delivering her.

Kirsty Birkenshaw, from March, attended A&E at Hinchingbrooke Hospital on August 9, 2021, concerned about abdominal pain and reduced movement of her baby after the 34-year-old and her partner Ricky Dickinson, 34, were involved in a car crash.

Kirsty, who was 30 weeks pregnant, was discharged the following day, however, she was re-admitted to Hinchingbrooke at around 9.15pm on August 11. She said she hadn’t felt Scarlettt move since 7pm.

That night the labour ward said it would perform computerised monitoring of Scarlett’s heart rate when Kirsty was on a ward in the morning, wrongly believing the machines wouldn’t work in A&E because they weren’t mobile. The ward also initially said it couldn’t send a midwife to see Kirsty in A&E because of staff shortages.

At around 10.20am on August 12, heart rate monitoring indicated Scarlett had an abnormal heart rate and was being starved of oxygen. She was delivered by category two caesarean – which according to the National Institute for Health and Care Excellence guidelines is where mum or baby are compromised but their condition isn’t life-threatening - just after 12.10pm.

Scarlett developed breathing problems and was put on a ventilator. She was transferred to the special care baby unit and then to a specialist hospital for treatment, however, she died aged five days from a brain injury caused by lack of oxygen and respiratory distress syndrome.

Following Scarlett’s death, Kirsty and Ricky instructed expert medical negligence lawyers at Irwin Mitchell to investigate. North West Anglia NHS Foundation Trust, which runs Hinchingbrooke Hospital, admitted a breach of duty.

The trust admitted that had Kirsty undergone obstetric review earlier, on the balance of probabilities, monitoring of Scarlett’s heart would have shown signs of reduced movement. A decision to delivery her by category two caesarean would have been made by 2.15am on August 12, with Scarlett delivered by 3.30am – nearly 10 hours before she was.

If Scarlett had been delivered by 3.30am, she would have been in a better condition and would have survived, the trust admitted through its lawyers.

Kirsty said: “We were so excited when we found out I was expecting. My pregnancy seemed to be going pretty smoothly and there weren’t too many concerns until the crash.

“I was in pain and was concerned Scarlett wasn’t moving as much, so we thought the best thing would be to go to hospital and get checked out.

“Even after I was sent home something didn’t feel right. When I was re-admitted I kept mentioning my concerns and that I hadn’t felt Scarlett move for some time. I appreciate the hospital was busy, but it felt like my concerns weren’t really listened to.

“It felt like things only started to progress when Scarlett’s heart was monitored but by then it was too late.

“The hurt and pain we feel now over Scarlett’s death is as raw now as it was when she was taken from us. There’s not a day goes by when we don’t think of her. It’s difficult not to think how she should be at home with us developing and causing mischief with her brothers and sister.

“We’d give anything to turn back the clock and for things to be different, but we know that’s not possible. We’ll forever cherish the precious moments we got to spend with Scarlett and she’ll always be part of our family.

“All we can do now is share what happened to us to make others aware. By speaking out we just hope lessons can be learned as we wouldn’t wish what we’re going through on anyone.

“People who’ve experienced baby loss also shouldn’t have to suffer alone as help and support is available.

“I’m very grateful for the support I’ve received from a fellow March Mum, who has also tragically lost a child. She’s worked to improve patient safety since the loss of her own child, using her knowledge of both NHS processes and the needs of bereaved parents to help us navigate the complex post-harm journey and communicate effectively with the Trust.”

Kirsty, who has three other children, was assessed in A&E around two hours after she was re-admitted to hospital on 11 August. At around 2am on 12 August, the labour ward was made aware of Kirsty’s concerns, including she hadn’t felt Scarlett move since 7pm the previous evening.

A decision was made to listen to Scarlett’s heart and perform computerised heart rate monitoring later that morning when Kirsty was on a ward. It was believed the machines wouldn’t work in A&E as they weren’t mobile.

An obstetrics doctor assessed Kirsty in the emergency department at around 2.30am and said she needed to be assessed by an obstetric registrar and computerised heart monitoring needed to be performed.

Kirsty was transferred to an assessment ward at around 4am. An hour later a member of the labour ward visited her and listened to Scarlett’s heart rate which was classed as regular.

During an assessment by a paediatric registrar at around 6.50am Kirsty was advised there was a risk Scarlett may be premature. A consultant then said computerised heart rate monitor was urgently required.

Monitoring took place while Kirsty was on the assessment ward and highlighted Scarlett’s abnormal heart rate and signs she was being starved of oxygen.

A decision was taken to deliver Scarlett by category two caesarean. Scarlett was delivered at 12.13pm. She died on 17 August.

Following Scarlett’s death, Kirsty has been supported by the Cambridgeshire charity Petals, which helps families affected by baby loss.

Abigail Salter, the specialist medical negligence lawyer at Irwin Mitchell representing Kirsty, said: “This is a truly tragic case which has left Kirsty and Ricky devastated. Understandably the last few years and trying to come to terms with the events that unfolded while having so many concerns has made trying to grieve for Scarlett even harder.

“While we’re pleased that we’ve been able to help provide Kirsty and Ricky with the answers they deserve, serious care failings have also been identified and admitted by the Trust.

“Every second counts when delivering babies in distress. It’s now vital that lessons are learned to improve maternity safety and help prevent other families having to endure the pain Kirsty and Ricky are going through.

“We continue to support the couple at this upsetting time and are working with the Hospital Trust so Kirsty and Ricky can access the specialist support and therapies they require following Scarlett’s death.”

Jo Bennis, Chief Nurse at North West Anglia NHS Foundation Trust, which runs Peterborough City, Hinchingbrooke and Stamford and Rutland Hospitals, said: “A serious incident investigation took place after this case in 2021, and we recognised that there were failures in the care of baby Scarlett Dickinson.

“The investigation found that there were lessons to be learned from the circumstances which led to Scarlett’s death and an action plan was created to reduce the risk of similar issues occurring again.

“The loss of a loved one is devastating, and we send our sincerest sympathies to Scarlett’s parents and family.”