‘Test of endurance’ in parents’ quest for answers over baby death

An internal hospital report over the death of a newborn girl was “like night and day” compared to the findings of an independent probe which identified numerous failings in her delivery care, an inquest has heard.

On Monday, Sarah Robinson said she and her partner, Ryan Lock, had experienced “a rollercoaster of emotions” in a fight for answers and “justice” since the birth of their daughter Ida Lock at Royal Lancaster Infirmary on November 9 2019.

Giving evidence at the start of an inquest, scheduled to last 17 days, Ms Robinson, from Morecambe, said there had been a “real sense of obstruction” from University Hospitals of Morecambe Bay NHS Foundation Trust, which runs the hospital.

The trust was the subject of a damning report in 2015 that found a “lethal mix” of problems at another of its maternity units at Furness General Hospital that led to the unnecessary deaths of 11 babies and one mother between 2004 and 2013.

The Morecambe Bay investigation, chaired by Dr Bill Kirkup, uncovered a series of failures “at every level” from the unit to those responsible for regulating and monitoring the trust.

Ida was transferred to the neonatal unit at Royal Preston Hospital and died a week later on November 16, the hearing at County Hall in Preston was told.

Ms Robinson told Dr James Adeley, senior coroner for Lancashire, that she had a good pregnancy and no concerns were raised as she opted for a water birth.

Medical notes revealed Ida’s heart rate had risen before Ms Robinson entered the birthing pool in labour at the Royal Lancaster but she said she was not made aware of the change.

Soon after she was asked to leave the pool, the inquest heard, but Ms Robinson said there was “no sense of urgency”.

She said “a lot of faffing about” followed as midwives “joked” about the complexity of using new labour beds but then the situation went from “light-hearted jokes to chaos” as Ida’s heart rate dipped.

Following their daughter’s death, Ms Robinson said she and her partner were “desperate” to speak to the hospital in a bid to find answers and a meeting was set up for late December 2019.

Ms Robinson said: “I was told ‘we don’t have anywhere to do this, is it OK to do this in the delivery suite?’

“That shocked me, I thought ‘absolutely not’.”

Instead the meeting took place in an office on Ward 17 where women are cared for before and after birth, the inquest heard.

Ms Robinson said being around newborn babies at the time was “torture” and “distressing”.

She said: “It seemed incredibly insensitive to our circumstances.

“We came away from that meeting thinking that Ida was in a very poorly condition when she was born.

“It took a long time to get over that meeting, I thought it was something I had done.

“The meeting didn’t provide any answers or explanations.

“We were provided with the medical notes.

“No-one took us through it, nothing to explain the notes.

“I had sorrow and anxiety which intensified for months, the only way I could describe myself was numb.

“I fell into a vicious circle, constantly questioning as to whether I was the reason that my daughter had died, and what had I missed. I felt so guilty.

“All of this was made more difficult by the lack of information from the trust which made it impossible for us to truly understand what had happened.”

Ms Robinson told the inquest it was “heartbreaking” to receive an April 2020 report from the Healthcare Safety Investigation Branch (HSIB) which identified failings in Ida’s delivery.

She went on to issue a complaint against the health trust via an email in which she questioned whether alternative actions from the midwifery team could have prevented the death of her daughter.

In the email, she added: “It should not be a test of endurance for bewildered and grieving parents to work out what happen.”

Ahead of the meeting in June 2020 the couple, from Morecambe, received the hospital’s root cause analysis (RCA) report of the issues with Ida’s delivery, the inquest heard.

Ms Robinson said: “We had a week to read what the trust had come up with as to how they had seen the incident.

“It was like night and day compared to the HSIB report.

“It was completely different.

“They said there were no care delivery issues whereas the HSIB report said there were many.”

In the meeting that followed she said the hospital acknowledged a number of failings in Ida’s delivery and care, she said, and were told that the RCA report would need to be rewritten.

Ms Robinson told the inquest: “I just questioned the integrity of it.

“Why was it not done right in the first place?”

The hearing was told that more than four years later the trust had accepted failings in a new “position statement” issued last December.

Ms Robinson said: “Myself and Ryan want to ensure that lessons are learned and effective system changes are made so that history doesn’t have to repeat itself.

“I hope that no other parents or families have to suffer in the way that we have.”

Giving evidence, Mr Lock said he was “concerned” that the failings in hospital care were “endemic” and he was of “the firm view” that he and his partner would have had no insight into the events at the Royal Lancaster but for the involvement of the HSIB.

He said: “This has changed me as a person.

“It’s a sheer test of endurance that no parent should endure….it’s a fight for justice, in my eyes.”

The inquest continues on Tuesday.