A five-day inquest concludes that the baby would have survived had a caesarean section been performed sooner
Piling on to the difficulties at Addenbrooke’s Hospital in Cambridge, HM Area Coroner Thea Wilson has concluded that a three-day-old baby would have survived at the hospital if a caesarean section had been performed sooner.
Emmy Russo died aged three days from a severe brain injury on 12 January 2024 at Addenbrookes’ Hospital, Cambridge. Recording a narrative conclusion, Wilson said that Russo had died of an acute hypoxic injury sustained shortly before her delivery. She concluded there were missed opportunities to expedite delivery by caesarean section, and had an earlier decision been made, on the balance of probabilities, she would have survived.
A five-day inquest at Chelmsford Coroners Court heard evidence regarding the management of Russo’s mother’s pregnancy, the advice given to her, and the decisions made regarding labour, delivery and the timing of induction. It also examined whether there were any delays in deciding to proceed with a caesarean section.
Following the inquest, Wilson said that she will issue a Prevention of Future Deaths (PFD) report on the information given to mothers on the induction of labour.
“This inquest has confirmed what Bryony and Daniel have long suspected – that Emmy’s death was entirely preventable,” said Firdous Ibrahim, senior associate solicitor at Leigh Day, who is representing the family. “There were missed opportunities to intervene when it was clear that Emmy was not coping with labour. Expert evidence confirmed that, had action been taken sooner, Emmy’s life could have been saved. These are not just clinical oversights; they are devastating failures with life-shattering consequences.”
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On the morning of 9 January, Russo’s mother began to experience contractions and the loss of thick dark brown mucous known as meconium. She was advised to head to hospital and was sent to the antenatal ward without assessment, where she was admitted for an induction of labour.
It was not until after 1500 that a midwife confirmed that meconium was present and a cardiotocography (CTG) monitoring started. The CTG trace showed multiple decelerations (temporary decreases in the fetal heart rate during labour) which later became more prolonged, but an emergency caesarean was not performed until much later that evening, by which point Russo had already suffered a hypoxic injury.
The inquest heard that meconium was identified during the labour – often a sign of foetal distress. A midwife acknowledged that the presence of meconium should have prompted more urgent action and, alongside the CTG concerns, warranted immediate senior review, which did not take place until seven hours after first admission.
The inquest also heard that Russo’s parents had requested a caesarean section much earlier on 9 January, but the midwife “laughed off” their request and insisted that birth be attempted naturally.
An MRI scan confirmed significant brain injury.
Giving evidence at the inquest, obstetrics expert Teresa Kelly reported that there were “multiple opportunities” during labour to offer delivery of Russo by caesarean section. She criticised the lack of information given to the mother by the antenatal midwife regarding the risks of continuing with pregnancy beyond 41 weeks.
She also said that had an earlier caesarean section been performed, Russo could still be alive. She told the inquest the management of Bryony’s labour was not appropriate and fell below reasonable standard – adding she would have expected an obstetrician to have assessed the mother much earlier, and for a caesarean to have been prepared. Other witnesses also suggested they wished they had acted on the foetal decelerations and offered a caesarean section sooner.
