‘Neglect’ contributed to death of newborn baby following failings in diabetes maternity care at Cambridgeshire hospital, inquest rules

Baby Charlotte Middleton died 40 minutes following her birth after staff at Hinchingbrooke Hospital in Huntingdon failed to act upon warnings which meant she was born two hours after she should have been, a coroner ruled. If she had been delivered when she should have been, Charlotte would have survived, the inquest found.

Her mum Laura, 40, was diagnosed with gestational diabetes during her third pregnancy. She had the condition during her other two pregnancies, so was aware of the risks and that her blood sugar levels had to be monitored.

Laura and her then husband Chris, 39, had a discussion with midwives and doctors, and opted for an elective caesarean section at 37 weeks due to having a large baby.

Upon admission to Hinchingbrooke Hospital, Charlotte’s heart rate was monitored using a cardiotocography (CTG) machine. The next morning after admission, Charlotte’s heart rate was found to have slowed and Laura was rushed to theatre for delivery.

Baby Charlotte was born in poor condition at 9.54am on 18 July 2019, and died shortly afterwards.

Following her daughter’s death, Laura instructed medical negligence experts at Irwin Mitchell to investigate her care under the North West Anglia NHS Foundation Trust and to support her family through the inquest process.

The family and their legal team are now calling for lessons to be learned.

Speaking after the inquest, Laura said : “We were all really looking forward to having Charlotte in our lives, and Isabelle and Harry couldn’t wait to have a little sister.

“During my time in the hospital before Charlotte was born, I wasn’t told of any problems. To hear that she had died was awful. When Chris arrived, I couldn’t bear to tell him what had happened. The senior midwife broke the news to him and brought Charlotte straight in. She put her into Chris’ arms and I watched his heart break. That will stay with me forever.

“Walking out of the hospital without our baby devastated us, and the drive home was spent in silence. Losing Charlotte is something we’ll never get over and we’ll never be the same, but it’s important for us as a family that we include her in as much of our life as possible and we talk about her every single day.

“I keep imagining Charlotte as a happy teething baby playing with her brother and sister. Sadly, that’s something we’ll never see, and while we can’t change what’s happened, we’re determined to campaign to improve care for others.

“While we have to live with the fact that Charlotte’s death could have been prevented, we wouldn’t want others to suffer the pain we do.

“Now the inquest is over we can move forward more positively knowing that Charlotte’s death wasn’t in vain. It’s just such a shame that this has to happen for changes to be made.”

The Trust admitted to “failings in ante-natal care” which “at least materially contributed” to Charlotte’s death.

The inquest was held this week at Cambridgeshire and Peterborough Coroners’ Court at Huntingdon Town Hall, and concluded Charlotte died as a result of complication of maternal diabetes in pregnancy and that neglect contributed to her death.

Coroner Lorna Skinner QC found staff did not act upon a series of Laura’s blood sugar level readings and an abnormal CTG reading. The scan demonstrated a need for Charlotte’s urgent delivery, the coroner said.

The scan reading combined with Laura’s pregnancy history should have seen Charlotte delivered by 7.40am at the latest. If she had been delivered by then she would have survived, the coroner ruled.

The Trust apologised to Laura through her legal team. In a bid to learn lessons from what happened it has since introduced a scheme entitled ‘Charlotte Training’ in the hope of helping to prevent further neonatal deaths.

Law firm Irwin Mitchell represents hundreds of families nationally who have been affected by issues in maternity care. It is campaigning to improve maternity services across the country and contributed to the Health Committee’s Maternity Safety Call for Evidence.

Guy Forster, the specialist medical negligence lawyer at Irwin Mitchell representing Laura, said after the inquest: “Losing a baby is an incredibly traumatic time for anyone, and to have to relive it all again at the inquest was undoubtedly difficult for Laura and Chris.

“Two-and-a-half years on, understandably they’re still struggling with the death of baby Charlotte and have battled with many questions over what happened to her. We thank the coroner for conducting such a thorough investigation and acknowledging the part that serious failures in care had in causing Charlotte’s death. The tragic but inescapable truth is that Charlotte’s death was entirely avoidable.

“While nothing will make up for their loss, we welcome the Hospital Trust’s acknowledgement that Laura should have received better care in a variety of respects, the many changes they have made to policies and procedures and their pledge to improve maternity safety through especially designed training named after baby Charlotte. It’s now vital that these procedures and training are embedded within the Trust’s maternity units so no one else has to suffer like Laura and Chris have.”

Laura and Chris have two other children together, Isabelle, nine, and Harry, five. In early 2019 the couple found out they were expecting their third child. Like her other pregnancies, Laura went on to develop gestational diabetes which required her glucose levels to be monitored.

On 5 July, at 34 weeks, a routine growth scan indicated that the baby was large. Following a further scan at 36 weeks, Laura was advised by medics to be admitted to hospital before 37 weeks. She and Chris decided to have a C-section.

On 17 July, Laura went into hospital. Charlotte was born by emergency C-section the following day, but died shortly afterwards.

Ms Skinner raised concerns about a lack of out of hours specialist diabetologist provision at Hinchingbrooke Hospital, particularly when the number of patients with the condition is increasing and such services are available at the Trust’s hospital in Peterborough.

The coroner recorded a narrative conclusion.

Laura has since been involved in the development of “Charlotte training” at North West Anglia NHS Foundation Trust, led by consultant obstetrician Dr Sangheeta Pathak. This is mandatory training surrounding diabetes in pregnancy, CTG interpretation and human factors, which is reportedly due to be rolled out across both North West Anglia NHS Foundation Trust sites. Charlotte’s family also hope that this can be replicated nationwide.