Mabel Olivia Williams tragically died at 6 days old of Hypoxic-Ischemic Encephalopathy (HIE) due to an undiagnosed uterine rupture on 10 September 2023. Mabel’s death came following failings in her, and her mother’s care during labour on 4 September 2023.
Following an inquest at Avon Coroners Court, HM Coroner Robert Sowersby identified multiple failings in the care provided to Mabel, and her mother Becky at Great Western Hospital in Swindon. HM Coroner concluded that Mabel Olivia Williams died because numerous indicators of distress, and of the increasing severity of her mother’s clinical condition went unrecognised by the midwifery staff involved in her care or were not conveyed to the clinical team to expedite her birth safely. Neglect contributed to Mabel’s tragic death.
HM Coroner found the following failures in relation to Mabel’s care:
1. Gross failings to provide basic care:
a. The allocated midwife failed to escalate the presence of frank blood in the toilet at 22:00;
b. The band 7 midwife who was escalated to at 22:45 considered the CTG as non-concerning when it was at least suspicious;
c. At 23:00 there was a failure to identify the CTG as pathological;
d. The failure to palpate Becky’s abdomen at any time. The court heard that this is not painful or harmful, it is a hand on the abdomen and can give useful information about potentially life-threatening conditions;
e. Failing to ask Becky about the nature of the pain, despite the known risk of uterine rupture;
f. Midwives failed to use the emergency buzzer appropriately;
g. The obstetrician was not called for assistance until a late stage and then was told he was not required, something the expert midwife described as “almost unbelievable”.
2. Failings where care fell below the expected standard of a competent midwife:
a. The band 7 midwife suggesting to adopt conservative measures for 20 minutes after 22:45, when the CTG had already showed reduced variability for 36 minutes;
b. Failing to do a vaginal examination, until Becky requested one herself;
c. Failing to stop oxytocin when concerns about the CTG were identified;
d. Not implementing the 3-3-3 rule for loss of fetal heart rate.
3. Further failings:
a. Failure to take informed consent for VBAC by not explaining the risk and implications of uterine rupture;
b. Failing to take informed consent for the fact of or commencement of oxytocin; and
c. The ongoing failing once things started to become suspicious to inform Mabel’s parents of what was going on and involve them in crucial decision.
The Coroner described Mabel’s parents as being “left as passive participants in episodes which witnessed a strikingly long catalogue of failings”.
The Coroner found that given the nature of Mabel’s injury, all the above failings more than minimally, negligibly or trivially contributed to her death.
Becky had previously had two vaginal births and a caesarean section. Becky wanted a low risk delivery but had a preference to have a vaginal birth after caesarean section (VBAC). Whilst Becky and Tom were told that there was a small risk of uterine rupture as a result of Becky having a VBAC, they were never told of the potentially very serious consequences of this, including serious injury or death to Mum and/or Baby.
The court heard that a uterine rupture is when a previous scar on the wall of the uterus starts to open. This can start as a thinning of the scar but can become a complete tear through all layers of the uterine wall, resulting in the fetus, amniotic fluid and/or umbilical cord entering the abdominal cavity.
The risk of uterine rupture increases further with induction of labour using a hormone drip, such as Oxytocin, for women having a VBAC. When Becky and Tom attended hospital on 4 September 2023 for a planned elective caesarean section, there was no discussion had with them regarding the starting of Oxytocin being a choice.
Becky and Tom went into hospital on 4 September 2023 understanding that there was a low threshold for converting to a caesarean section, however, at no point during the labour process was this offered to them, despite the court hearing that there should have been a discussion with Becky and Tom at various points during the labour process.
Around 22:00 Becky went to the toilet where she passed fresh blood in the toilet. The coroner found as a fact that this was shown to the allocated midwife, but the midwife failed to record it and escalate it as she should have done. This was a potential sign of uterine rupture. Between 22:00-22:25 Becky also began to experience significant and constant pain, and the CTG started to demonstrate reduced variability, both further potential signs of a uterine rupture.
The coroner found that if the blood in the toilet, constant pain and reduced variability were escalated to an obstetrician, a category one caesarian section (for delivery within 30 minutes) would have been called. As a result of this Mabel would have been born at 23:00, 51 minutes before she in fact was. On the evidence before the court, delivery at or around 23:00 would have likely been before:
Considering all those features the coroner said “it is overwhelmingly likely if not for the identified failings, and in particular not escalating the frank blood and taking into account the nature of Becky’s pain, Mabel would have survived”.
HM Coroner has asked the Trust to provide him with further evidence within 7 days to enable him to consider whether his duty to write a prevention of future deaths report is engaged.
It was an honour to represent Mabel’s family and learn about Mabel’s devastating story. This is such a tragic case, and it is hoped that no other parents have to go through the pain of Becky and Tom in these circumstances.
Emily was instructed by Amy Milner from CL Medilaw.
