Blackpool Victoria Hospital staff failed to properly examine heavily pregnant woman before giving her drug

Giving the heavily pregnant mother the drug was proved to be negligent - but it was deemed insufficient to prove a connection between the negligience and complications suffered during birth

First published on 15 August 2024

Medics at Blackpool Victoria Hospital failed to properly examine a heavily pregnant woman before inappropriately giving her a drug to help with contractions, a court has been told.

The blunder, which has been admitted by bosses at the Whinney Heys Road hospital, is feared to have sparked complications for the mother-to-be’s baby, who was blue, floppy and not breathing when he was born.

But a judge said there is not enough evidence to prove the boy’s traumatic birth is behind his range of medical issues - including microcephaly, a rare birth defect that causes one’s head to be much smaller than usual, and developmental difficulties -  and denied him compensation.

In a high court case brought against the NHS trust running the Vic, the primary school-aged boy, who cannot be named for legal reasons and has been given the moniker LN, sued for “damages for personal injuries and consequential losses allegedly sustained as a result of the negligent management of his mother’s labour and birth”, documents obtained by The Blackpool Lead said.

But, after hearing from a series of professionals and examining the evidence over several days, judge Richard Pearce said it is “sometimes not possible to show any connection between the negligence and the bad outcome”.

He said: “I have no doubt that this judgement will be a disappointment for the claimant’s family who have fought hard for him.

“They can be reassured that the evidence in this case has been comprehensively explored by experts and lawyers on their behalf.”

Marie Forshaw, the hospital’s acting executive director of nursing, midwifery, allied health professionals and quality, said: “I would like to extend our apologies to the family involved in this case.”

Scandal and controversy

The legal row erupted during a period of scandal and scrutiny in maternity care and at the hospital, which has been rocked by several controversies in recent years, including a poison plot on the stroke ward and the unsolved murder of a grandmother.

The Vic’s maternity unit, which delivers around 3,000 babies a year - an average of just over eight a day - was rated “requires improvement” after its last inspection by the Care Quality Commission (CQC), the hospitals watchdog, in 2022.

The inspection, which was unannounced, was carried out “partly” because of “concerns raised over how the service was managing with low staffing to ensure women and babies received safe care and treatment”, the CQC’s report said.

It said “serious concerns” were uncovered, including “ineffective processes to manage and mitigate the risks in relation to the lack of enough suitably qualified midwifery staff to care for women”, which were “contributing to significant risks to women receiving timely and appropriate care and treatment, exposing them to the risk of harm”.

The CQC’s report, which did say the Vic had come up with an action plan to try and improve, added: “Staff did not always provide effective care and treatment and did not always meet expected patient outcomes.”

Clear shortcomings

The Vic did not say how well staffed the delivery suite was on the day of LN’s birth, with Forshaw saying it would also be “inappropriate” to comment on the “specifics of a patient’s individual care”.

She admitted, however, that the judge “clearly highlighted some shortcomings in the care we provided and we recognise that the patient involved has life-changing conditions that impact not just him but his family also”.

She said: “We would like to offer reassurance that we continue to work hard to make sure women remain confident and feel safe when giving birth at Blackpool Victoria Hospital.”

Forshaw said the “safety of mothers and their children is of utmost importance to all of us” and said that, since the CQC’s inspection, bosses have “worked hard to make significant improvements”.

“Following the inspection, we developed a comprehensive improvement plan with oversight from the Maternity Safety Support Programme and conducted several CQC engagement sessions,” she said.

“Key improvements include establishing a cohesive leadership team and enhancing the safety and quality of care for women and their families.

“We have particularly focused on the induction of labour and improving our governance processes. This has been achieved by partnering with external colleagues, including the Local Maternity and Neonatal System and the North-West Neonatal Operational Delivery Network.

“These actions, among others, ensure we continue to provide caring, safe and respectful maternity services for the women and babies in our communities.”

LN’s mother, who also cannot be identified legally after an anonymity order was put in place by the judge, was admitted to the Vic’s delivery suite with a medical history of antepartum bleeding when she was just over 41 weeks pregnant, court papers reveal.

She was having contractions and, at 9.40am, an examination showed she was 3cm dilated (dilation of around 10cm is needed for childbirth) and her waters had broken.

At 10.15am, she was 4cm dilated.

Fifteen minutes later, a doctor decided to give an infusion of Syntocinon, which can be used to quicken labour, but it was delayed for several hours after LN’s mother asked for an epidural to help with the pain.

The drip started at 1.45pm, more than three hours later, at an initial dose of 12ml per hour.

This, documents suggest, may have caused LN’s mother to suffer uterine hyperstimulation, a serious complication that can lead to foetal heart rate abnormalities and foetal hypoxia - essentially a lack of oxygen for the baby.

It also allegedly led to the baby suffering an abnormally fast heart rate, the papers added.

Judge Pearce said: “The administration of Syntocinon is admitted to have been negligent.”

In his judgement, he quoted a report saying: “By 1.45pm, there was evidence of tachysystole (excessive uterine activity), potentially attributable to the antepartum haemorrhage and/or a small placental abruption.

“It is accepted that in the circumstances, a further review, including a vaginal examination to assess progress in labour, ought to have been carried out before commencing Syntocinon; such a review would have identified that there had been significant progress in labour since the previous vaginal examination at 11.15am; and the appropriate decision would therefore have been not to commence Syntocinon, but to maintain observations.”.

The Blackpool Lead asked the hospital why the examination was not carried out but the question went unanswered.

Syntocinon and its effects

An article in the British Journal of Midwifery in 2017 said that “although the use of Syntocinon is regarded as a relatively safe intervention during labour” and the drug can be a “life-saving intervention for many women”, its “effects can be unpredictable”.

It said: “Large doses of Syntocinon can increase the resting tone of the uterine muscle by creating more frequent, longer and stronger contractions.

“An increased resting tone of the uterine muscle can reduce blood flow to the uterus and placenta, as shown in preliminary animal studies and result in myometrial ischemia (reduced blood flow to the muscular layer of the uterine wall) and increased pain sensation. The ischemia may in turn compromise foetal replenishment of blood and oxygen between contractions and result in abnormal foetal heart rate patterns, foetal distress and even uterine rupture.”

LN’s family argued that administering Syntocinon ultimately led to the boy suffering hypoxic encephalopathy (HIE) - a type of brain damage caused by a lack of oxygen to the brain before or shortly after birth.

The Vic, however, argued that the youngster, who was born with the umbilical cord around his neck, either did not suffer HIE or, if he did, it was not caused by the Syntocinon.

The boy was delivered normally but was not breathing. Resuscitation efforts were started and, 15 minutes after birth, he began gasping irregularly, documents show.

His condition improved and he was admitted to the neonatal unit.

An X-ray then showed a large tension pneumothorax - a life-threatening pocket of trapped air in the chest that can be caused by resuscitation.

A chest drain was carried out and the boy was put on the neonatal intensive care unit and treated.

After then having possible seizures, the newborn was transferred to a hospital in Manchester.

After hearing from a string of experts, Judge Pearce appeared to suggest that none of them were able to paint a clear and conclusive picture as to why the boy has been left with difficulties, which, according to a neuropsychologist’s report, include delayed development, visual impairment, “low average verbal ability, low average adaptive functioning, subtle difficulties with executive functioning and intact memory”.

The judge wrote: “In drawing the threads of the expert evidence together, it is clear that the course of the (boy’s) delivery, his neonatal state, his longer-term outcome and the available objective signs do not hang neatly together to produce a coherent picture.

“The various experts have each sought to address the issue from their own viewpoints, looking insofar as they felt able to at the opinions of experts from other disciplines to inform their opinions. Nonetheless, no expert has been able to come up with a formulation which is consistent with all of the evidence before the court.”

And he ruled: “I conclude that, whilst the evidence is by no means unequivocal on the issue, it is more likely than not that the claimant’s condition at birth reflected the fact that he was suffering a hypoxic-ischaemic encephalopathy.”

Considering whether the “supposed HIE” was the cause of some or all of the boy’s developmental delay and other difficulties, the judge said the “common ground” is that a sight condition was “probably caused by a genetic abnormality”.

He said “evidence on the issue of microcephaly is relatively clear” and referred to the opinion of Dr Shakti Agrawal, the case’s “only one expert who is a paediatric neurologist”.

Agrawal, the judge wrote, believed the condition “is more likely than not part of the same genetic abnormality that has led” to the child’s vision problems.

The judge said: “I am not persuaded that the microcephaly is the result of any birth asphyxia and consequently am not persuaded that it is secondary to the HIE.”

In an attempt to persuade the court, the Vic’s counsel said the boy’s “continuing problems have a single unifying cause, namely a genetic syndrome”.

But Judge Pearce was unconvinced, adding: “Were a genetic syndrome to have been identified I might of course have reached a different view, but it has not.”

He went on: “However, I am not persuaded by the claimant’s case that he suffers the continuing consequences of HIE that cause or contribute to the various aspects of his condition described by the paediatricians and neuropsychologists.

“I cannot exclude the possibility that they have some contribution. But there is insufficiently clear evidence here for the claimant to satisfy the burden of proof on this issue.”

The judge concluded: “Whilst the claimant shows that he suffered HIE as a result of the defendant’s admitted breach of duty, he cannot show on the balance of probabilities that he has suffered anything other than the immediate depression of his condition at birth as a result of the HIE.”

The boy and his family were represented in court by Christopher Melton KC, who could not be reached for a comment prior to publication.

Recent clouded history at Blackpool Victoria

The Vic’s recent history, which has threatened to overshadow the hard and dedicated efforts of much of its workforce, includes the secret sedating of stroke patients by nurses Catherine Hudson, 54, and Charlotte Wilmot, 48, so they could have an “easy shift”.

A major investigation was opened by police after a student on work experience blew the whistle, with forensic searches of Wilmot’s phone revealing a WhatsApp message reading: “I sedated one of them to within an inch of her life lol”.

That investigation, which saw a number of funerals delayed and post-mortem examinations carried out, then uncovered the violent killing of stroke unit patient Valerie Kneale, 75, who was so badly abused - possibly sexually - that she bled to death internally.

The suspicious nature of her death only came to light during the police's poisoning probe.

An unidentified healthcare professional was arrested on suspicion of sexual assault, rape and murder but later released without charge.

An appeal on Crimewatch failed to lead to a breakthrough, while the offer of a £20,000 reward from Crimestoppers to find and convict the murderer has so far gone unclaimed.

Kneale's niece, Lisa Jaffier, told the BBC programme her loved ones have been left with a “huge wound that can’t even begin to heal until we find out who is responsible so we can get justice”.

And Lancashire Police’s DCI Jill Johnson declared: “It’s a real worry to the investigation and to the hospital that this could be just one of a number of attacks at the hands of someone who is a predator and who may have committed previous attacks of this nature.”

There has been a string of other alarming incidents, too, including a “stressed” Vic junior doctor being jailed for groping girls as young as 10 in the street and care worker Hernando Puno, 52, being sent to prison for sexually assaulting five hospital colleagues.

Puno grabbed and slapped some of his victims’ bottoms, Burnley Crown Court was told, and approached others from behind and kissed and hugged them.

One of his victims made a formal complaint to the Vic about Puno’s perverted ways almost a decade before he was finally jailed but “did not appear to be taken seriously”, the court heard.

In February, agency doctor Xowi Mwimbi became the fifth Vic health worker to be jailed in just a year after he punched a vulnerable dementia patient.

He claimed he acted in self-defence after being racially abused but a jury saw through his protestations and convicted him.

Judge Heather Lloyd told Mwimbi at Preston Crown Court: “'It is clear you failed in your first duty of care to a patient, which is to do no harm.

“This patient had very complex needs and you ignored warnings over how he should be approached when dealing with him.

“Even a student nurse was aware of the warnings and this would not have happened if this patient had been approached with care.

“After all your years of practice, you thought you knew better.”