Prevention of Future Deaths report – Poppy Harris (20 October 2021)

Summary

Poppy Harris was born at Milton Keynes University hospital on 23 November 2020. Following a protracted labour, she was delivered using Kielland's forceps. She was transferred to John Radcliffe Hospital in Oxford where it was discovered that she had suffered a spinal cord injury and despite all efforts and care she died on 24 March 2021.

Content

In his report the Coroner states that Poppy’s death was the result of the inappropriate use of Kielland's forceps during delivery for which her mother had not given informed consent.

He expresses concerns that when Poppy’s mother came to the hospital she did not have a birth plan and the midwives did not attempt to complete one. As a result of this there was no indication as to her preferences for treatment and care throughout her labour. The Coroner also suggests that the Hospital should carry out an urgent review of the use of Kielland’s forceps and in his view decide that they should no longer be used.

This report was sent to Milton Keynes University Hospital NHS Foundation Trust, the Royal College of Obstetricians and Gynaecologists, the Care Quality Commission and the General Medical Council.