A senior coroner has confirmed that a Prevention of Future Deaths Report will be issued following the inquest into the death of baby Delilah-Jayde Arnold, who died aged one week after suffering a catastrophic lack of oxygen before birth at Leeds General Infirmary.
On 27th November 2024, Kelly Harris attended Leeds General Infirmary Hospital at 06:00am in light of her waters breaking. To ensure the health and wellbeing of Delilah, her heartrate was monitored without any issues using a cardiotocraph (CTG), but a later stage, there were intermittent losses of contact with the CTG. At approximately 4:54pm it was noted that that there were declarations (dips and slowing down in heart rate) which were becoming deeper and Delilah was taking longer to recover back to her baseline heartrate. The midwife, Amy Nevet, in charge of both Kelly and Delilah’s care made a decision to use fetal scalp electrodes (FSE), clips which attach to a baby’s head, to regain monitoring of Delilah’s heartrate. At one point, additional FSEs had to be brought in from another hospital due to not having this equipment at Leeds General Infirmary. Numerous attempts were made to apply these clips, to regain a trace of Delilah’s heartrate, but all unsuccessful. Kelly and Delilah were eventually escalated to senior members of staff, by which time the Coroner found there had been between 33 and 42 minutes without monitoring of Delilah’s heartrate. Consultant Dr Tracey Glanville attended and upon examination, it was confirmed at 5:45pm that an emergency C-section would be carried out to deliver baby Delilah. A C-Section took place and Delilah was born at 6:07pm with no signs of life and a heart rate of 60bpm. Delilah was transferred to the Neonatal Intensive Care Unit whereby she received critical care and treatment. Despite resuscitation efforts, Delilah passed away at 5:34pm on 4th December 2024. A postmortem report confirmed Delilah died from a hypoxic ischaemic encephalopogy subsequent to perinatal asphyxia. Due to an event, shortly before birth, Delilah’s brain was starved of oxygen thus causing a brain injury and her to pass away.
Following Delilah’s death, a Maternity & Newborn Safety Investigation took place which concluded that:
The inquest, heard at Wakefield Coroner’s Court before HM Acting Senior Coroner Oliver Longstaff, concluded that Delilah’s death followed a prolonged period during which her heart rate was not being monitored in labour. The coroner found that there was no fetal heart-rate monitoring for between 33 and 42 minutes before her delivery, and that the loss of monitoring was not recognised as a risk requiring escalation.
In his narrative conclusion, HM Acting Senior Coroner found:
“For between 33 and 42 minutes prior to her delivery there was no monitoring of the fetal heart rate and it was not identified as a risk to Delilah. The focus was on restoring contact rather than escalating it. Had it been managed in line with a protocol introduced after her death, it is likely she would not have died as she did.”
Moreover, HM Acting Senior Coroner has confirmed that a Prevention of Future Death Report will be produced and sent to the Clinical Director of National Institute for Health and Care Excellence (NICE).
A Prevention of Future Deaths Report, often referred to as a Regulation 28 Report, is a statutory mechanism available to coroners in England and Wales. Where a coroner identifies circumstances during an inquest that create a risk of future deaths, and believes action should be taken to reduce or eliminate that risk, they have a legal duty to report those concerns to the person or organisation with the power to make changes. Recipients must provide a written response setting out what action they will take.
The family said:
“We are however pleased that the Coroner has made a prevention of future deaths report to the Clinical Director of the National Institute for Health and Care Excellence to consider introducing a time frame for loss of monitoring to be introduced into the national guidelines. We hope that NICE will implement that change nationally so that other families don’t have to go through this in future.”
Richard O’Keeffe represented the family at the inquest, instructed by Jenny Fraser of Fosters Solicitors.
You can read the BBC’s coverage of the inquest here, ITV’s coverage here, and Yorkshire Evening Post’s here.
