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Death of a baby at Kingsmill Hospital, run by Sherwood Forest Hospitals NHS Trust, was contributed by neglect, a Coroner concluded





A baby who died from a brain injury following a delayed labour and delivery was failed by staff at a hospital, a Coroner has concluded.

Arlo River Phoenix Lambert died on Mach 9, 2023 at Kingsmill Hospital, run by Sherwood Forest Hospitals NHS Trust, at five days old.

The Coroner found that Arlo’s death was “contributed to by mismanagement of labour and multiple missed opportunities to have expedited his delivery.”

Arlo River Phoenix Lambert
Arlo River Phoenix Lambert

The Coroner concluded that neglect contributed to Arlo’s death which came from “a failure to follow Trust guidance.”

Miss Lambert, Arlo’s mother, was induced at 40 and two weeks, and following spontaneous rupture of membranes (SROM), she was left for 17 hours without any attempts made to progress her labour.

This gave time for the risk of infection to materialise, the Coroner found.

During that time, staff failed to properly review Miss Lambert’s care plan and discuss modes of delivery with her, when concerns were raised about the position of the baby and her labour was failing to progress.

The Coroner found evidence of “multiple missed opportunities to have expedited Arlo’s delivery which would probably have prevented his death.” She has issued a Prevention of Future Deaths Report.

Since Arlo’s death Miss Lambert has suffered from post-traumatic stress disorder.

Furthermore, the Coroner also made a complaint to the General Medical Council in relation to the actions by Specialist Registrar.

In oral evidence, they said that they would “cross [my] fingers behind my back and hope and pray the mother would go into labour” instead of implementing an appropriate care plan.

A post-mortem autopsy found that Arlo’s brain showed evidence of hypoxic-ischaemic injury, which is where brain cells die because of a period of time spent without adequate oxygenated blood supply, which can occur as a result of delayed delivery following fetal distress.

The Coroner found an abundance of issues with the pre-natal care of Miss Lambert between her induction of labour at 17.15 hours on March 2, 2023 and Arlo’s birth at 4.26am hours on March 4.

It was heard that even before Arlo’s birth, Miss Lambert faced failings in her antenatal care.

At 38 and six weeks gestation, she attended the hospital for a growth scan and was offered induction of labour at 40 and two weeks due to some concerns around growth of the fetus.

This course of action was outside the national definition for slowing fetal growth and an induction of labour was not indicated, but there was no evidence that Miss Lambert was made aware of that fact, the Coroner concluded.

If Miss Lambert had not been offered induction of labour at 40 and two weeks, she would likely have gone into labour spontaneously, the Coroner stated, and “her previous labours suggest she would not have faced any challenges delivering Arlo.”

At 11.33am on March 3, 2023, the baby’s head was found to be presenting high in the pelvis, but there was a missed opportunity to consider mode of delivery and to have counselled mum on the risks and benefits of continuing with induction of labour, or caesarean delivery, in accordance with national guidance, the Coroner found.

CTG monitoring was discontinued which was also against national guidance, so the midwives were unable to continuously monitor for any signs of fetal distress.

At 5pm, after being asked to confirm the position of the fetus with an ultrasound scan, it was the registrar who wrote a delivery plan without consulting Miss Lambert’s wishes and without knowledge of her situation.

It was heard that if the induction of labour policy had been followed when labour was not established two hours after SROM, delivery by either method would probably have avoided Arlo’s death.

At the ward around 9.43pm, there was a communication failure between the midwife and obstetric team to understand that there had been blood stained liquor, which again led to a missed opportunity to consider the mode of delivery.

At 3.58am on March 4, doctors decided to proceed to a category one caesarean section for suspected placental abruption.

Just before 4.30am, Arlo was delivered by a difficult caesarean section due to his position, following a delay by the midwives recognising that there were complications and alerting the obstetric team for assistance.

Baby Arlo was in a compound position with both a leg and an arm above his head.

It was apparent on delivery that there had been a placental abruption given the volume of blood and clot within the uterus.

He was transferred to the neonatal unit at the Queen’s Medical Centre for specialist care, but he passed away five days later.

Specific failings highlighted by the Coroner include the staff’s failure to follow the Trust’s induction of labour policy to augment labour — by administering a hormone drip to bring on contractions — if it is not established within two hours after SROM for a multiparous mother.

Had Arlo been delivered sooner, he “would more likely than not have survived,” the Coroner concluded.

Chantae Clark of Tees Law, acting for the family, said: “These tragic events were preventable if Sherwood Forest Hospitals NHS Trust had followed guidance and acted on the warning signs in the hours before Miss Lambert’s labour.

“It is hard to believe that in such an advanced healthcare system, a mother should suffer the treatment that she did and that a baby should die because of neglect.

“The immense toll on Arlo’s family shows the devastating impact of these failings. It is of some comfort to the family that the Coroner has carried out such a robust investigation and has found evidence of neglect and issued a Prevention of Future Deaths Report.

“The family sincerely hopes that the Trust implement urgent changes to prevent another avoidable disaster befalling any other family.”



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