A midwifery boss has admitted that she repeatedly failed to inform the health watchdog about issues which contributed to a newborn baby's death.
Ida Lock was born at the Royal Lancaster Infirmary (RLI) on the morning of November 9 in 2019 in a "poor condition" and with the umbilical cord wrapped around her neck.
Ida's mum Sarah Robinson, from Morecambe, had gone to the hospital's central delivery suite at 7.30am after her waters broke the previous day. Sarah, who was 40+1 weeks pregnant, had previously attended the hospital after noticing reduced foetal movements.
Despite midwife Lisa McGrow noticing that the baby's heartrate had dropped to 100bpm, below the acceptable range of 110-160bpm, Sarah was allowed to enter the birthing pool.
Less than 20 minutes later, after Ms McGrow and a more senior midwife, Amanda Sailor, called for assistance, a doctor arrived and immediately said "we need to get this baby out now".
However, after Ida was delivered, not breathing, there was a period of three and-a-half minutes when Mrs Sailor and delivery suite coordinator Celia Sykes were carrying out "ineffective" CPR. When Dr Matthew Phillips came into the room he ensured that Ida was properly resuscitated.
Ida was transferred to the neonatal intensive care unit at the Royal Preston Hospital. Her parents were informed that she had suffered a severe brain injury, due to a lack of oxygen, and she sadly died seven days later.
The inquest started earlier this month and on the 25 February heard from Carol Carlile who, in 2019, was the head of midwifery at the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) which runs the RLI.
Ms Carlile explained that she had been appointed by the trust to oversee the implementation of the 18 recommendations made following the publication of the Kirkup Report in 2015. Dr Bill Kirkup CBE had overseen a public inquiry into maternity services at UHMBT after the deaths of 11 babies and one mother.
The inquest heard that Ms Carlile had "signed off" a Root Cause Analysis into Ida's death, carried out by the trust contrary to Care Quality Commission guidance. The report published following that analysis, and 'signed off' by Ms Carlile, concluded that "everything went well" with Ida's birth.
Just a few weeks later the independent Healthcare Safety Investigation Branch (HSIB) published its own findings which highlighted several failings which it found contributed to Ida's death.
Ms Carlile had no explanation as to why, despite there being six separate 'codes' which would have required her to report Ida's case to the Care Quality Commission, she had failed to do so and said: "I can't recall why I didn't do that. I should have done."
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Source: Lancs Live, 26 February 2025
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