High-risk pregnancy failings

Doncaster Royal Infirmary
Doncaster Royal Infirmary

Failure to advise a teenage mum-to-be to come into hospital with abdominal pains, days before the death of her baby was a ‘missed opportunity’, an inquest heard.

Emily Louise Reynolds, aged 16, who was categorised as having a ‘high-risk’ pregnancy because her baby was breech was told the pains, that started the day she was booked in for a caesarean, were ‘normal’.

This was a missed opportunity to assess her, observe her and diagnose the placental abruption

But the court heard the burning and abdominal symptoms Miss Reynolds described to Doncaster Royal Infirmary midwife Catherine Blakey could have been the first indication of a placental abruption – a condition that can deprive a baby of oxygen.

Coroner Nicola Mundy confirmed the cause of Rhogan Lee James Dove’s death was hypoxic-ischemic encephalopathy – a brain injury caused by oxygen deprivation due to the internal placental abruption.

The court heard conflicting evidence about the phone calls to the triage department at Doncaster Royal Infirmary on March 24.

First-time mum Miss Reynolds told the inquest both she and her auntie Julie had a conversation with the midwife about the symptoms but in evidence midwife Catherine Blakey said she could ‘not recall’ speaking to Julie.

But Miss Mundy said she was satisfied both had spoken to Ms Blakey and described the symptoms fully to her.

Miss Mundy said the decision not to invite Miss Reynolds into hospital was a ‘missed opportunity’.

She added: “Emily easily met the criteria in triage guidelines at that time and should have been brought into the unit for further assessment.

“This was a missed opportunity to assess her, observe her and diagnose the placental abruption that had occurred around midday.”

Recording a narrative verdict, Miss Mundy said: “Rhogan Lee James Dove suffered a catastrophic brain injury following an internal placental abruption which occurred several hours prior to his delivery.

“There was a missed opportunity to assess his mother in triage earlier that day which would have likely led to diagnosis of this condition and thus the early delivery of Rhogan which would have greatly increased his prospects of survival.

“He passed away on 28th of March 2015.”

Miss Mundy said she was satisfied a number of changes and improvements had been made at Doncaster Royal Infirmary following Rhogan’s death.