A coroner has concluded that a newly born child died because of missed opportunities to escalate the mother’s care and inadequate staffing levels at University Hospital Lewisham.
The assistant coroner for South Eastern England has concluded that a newly born child died at University Hospital Lewisham (UHL), part of Lewisham and Greenwich NHS Trust, because of missed opportunities to escalate the mother’s care and inadequate staffing levels on the antenatal and labour wards.
The inquest into the death of Khalia Thomas was held between 19 and 22 May at Inner South London Coroner’s Court.
Thomas’ mother arrived at UHL early on 25 November 2022, in the latent stage of labour and struggling with painful contractions.
The mother told UHL staff that she could no longer feel her daughter moving and was put onto a cardiotocography machine for continuous monitoring. Evidence showed, however, that despite significant drops in the baby’s heart rate Lucy was wrongly categorised as a low-risk pregnancy and her care was not escalated in line with the trust’s own policy.
The mother was eventually taken to theatre, and Thomas was delivered by C-section, but she died just 38 minutes later.
At the inquest, witnesses from Lewisham and Greenwich NHS Trust described staffing issues as “dire” and said that staff felt “desperate” because of how stretched they were with other high-risk births. Despite this level of acuity, available midwives who were on-site at a training day were not brought back onto the wards.
The coroner noted in her conclusion that the mother was also wrongly taken off CTG monitoring for a time because of a miscommunication between staff.
Tragic and preventable loss
Recording a narrative conclusion, the coroner found that opportunities to escalate the mother’s care were missed and had Thomas been born earlier she could have been resuscitated and would not have died when she did.
“This inquest has exposed a tragic and preventable loss… The evidence clearly showed that Khalia’s distress went unrecognised for far too long, and multiple opportunities to intervene were missed. The decision to remove continuous foetal monitoring was indefensible given the signs already present, and the delays in escalation proved fatal,” said Frankie Rhodes, senior associate solicitor at the law firm Leigh Day, who represented the family.
She went on to emphasise the facts that the mother was incorrectly classified as low risk, there were insufficient staff to take her to the labour ward to provide one-to-one care, there was a failure to redeploy staff from on-site training to assist, and critical errors in communication which meant that there was no holistic assessment carried out by either of the obstetricians on the ward.
“If this had taken place, Khalia’s delivery would have been expedited,” she continued.
Counsel for the family was Cressida Mawdesley-Thomas of 12 King’s Bench Walk.
