Charlotte Middleton inquest: Need to deliver baby who died 'obvious'

The need to urgently deliver a baby who died shortly after birth "should have been obvious", a coroner said.

Charlotte Middleton died 41 minutes after being delivered at Hinchingbrooke Hospital, Cambridgeshire in July 2019.

A coroner said heartrate monitoring which demonstrated a need for urgent delivery was not acted upon and her death was "contributed to by neglect".

North West Anglia NHS Foundation Trust, which runs the hospital, said it had "ensured lessons have been learned".

Lorna Skinner QC, assistant coroner for Cambridgeshire and Peterborough, said Charlotte's mother Laura had gestational diabetes and was admitted to the hospital in Huntingdon about 36 weeks into her pregnancy in preparation for a planned caesarean-section.

Ms Skinner said that from 16:00 BST to 09:00 the following day Charlotte's mother's "blood glucose levels were above the normal limit, sometimes significantly so" and found "insufficient measures were taken to gain control of them".

She said that at 05:54 cardiotocography (CTG) monitoring, which measures the baby's heartrate, "revealed a clear prolonged deceleration in Charlotte's heartrate shortly before 06:30".

The coroner said this, coupled with other results and in the context and length of the pregnancy, "should have led to a decision for delivery to have been taken at 06:40, with delivery of Charlotte following within an hour".

"Had this occurred, Charlotte would have survived. Instead, she was delivered at 09:54 and died at 10:35 at Hinchingbrooke Hospital on 18 July 2019," Ms Skinner said.

The coroner added that Charlotte's "need for delivery should have been obvious" and that the "failure can be characterised as gross and is so serious that the total picture in relation to Charlotte amounts to neglect".

In her narrative conclusion delivered in an online hearing, the coroner found Charlotte died from natural causes - delayed villous maturation of placenta, caused by maternal diabetes.

"Her death was contributed to by neglect in that CTG monitoring which demonstrated a need for her urgent delivery was not acted upon," said Ms Skinner.

Speaking after the inquest, Charlotte's mother Laura said "while we can't change what's happened, we're determined to campaign to improve care for others".

She said after the midwife told Charlotte's father Chris that the baby had died: "She put her into Chris's arms and I watched his heart break. That will stay with me forever."

"Walking out of the hospital without our baby devastated us, and the drive home was spent in silence.

"Losing Charlotte is something we'll never get over and we'll never be the same, but it's important for us as a family that we include her in as much of our life as possible and we talk about her every single day."

Dr Kanchan Rege, North West Anglia NHS Foundation Trust's chief medical officer and deputy chief executive, said it had "ensured lessons have been learned in this tragic case and further training has also been put into place in order to prevent this from happening again".

"We have been in touch with the family throughout and offer our sincerest condolences and continued support, should they require it."

Guy Forster, the specialist medical negligence lawyer at Irwin Mitchell representing Ms Middleton, said they "welcome the hospital trust's acknowledgement that Laura should have received better care in a variety of respects [and] the many changes they have made to policies and procedures and their pledge to improve maternity safety through especially designed training named after baby Charlotte."

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