The safety of Britain's maternity services will be challenged this week at an inquest on a baby who died at a hospital unit which was being monitored for safety by the NHS regulator.
Ebony Rose McCall-Comley was delivered, at 7lb 4oz, by emergency Caesarean at Milton Keynes Hospital on 9 May 2009. She was full term but died 30 minutes later, despite doctors' efforts.
Her grandfather, Terry McCall, claims that an abnormal heart trace was not acted on, the Caesarean was delayed, and that medical staff disagreed about how to manage the birth. If confirmed, this would suggest Ebony's death has disturbing parallels with that of Romy Feast, who died in the same unit in June 2007 after an emergency Caesarean.
That death led to an investigation by the Healthcare Commission which found misinterpretation of foetal heart monitor traces "was a common feature" and "there was no evidence of lessons [being] learnt". It said the lack of a fully staffed 24-hour obstetric theatre led to "debates as to what qualifies as an emergency". The hospital was ordered to improve its performance and a follow-up study was done in September; the report is still awaited.
The Healthcare Commission investigation was triggered by the inquest into Romy's death in February 2008, at which deputy coroner Thomas Osbourne, who is to conduct next week's inquest into Ebony's death, concluded that the hospital committed a "catalogue of mistakes". He criticised the lack of team-work and said experienced midwives had felt unable to question the decisions of doctors.
"It is about time such unwritten rules are left in the 19th century where they belong and that obstetrics and gynaecology embrace the modern world," he said. "It is a regrettable situation if the views of midwives who have 30 years' experience cannot be voiced and, if they are voiced, are disregarded." Mr McCall said there were disagreements about how Ebony's delivery should be managed, a disputed heart trace and arguments about whether her case constituted an emergency.
Ebony's mother, Amanda McCall, 17, was admitted to the maternity unit on 9 May with pains in her abdomen, Mr McCall, a police sergeant, said. She was investigated and remained in hospital until early the next morning when a sudden fall in the baby's heart beat, triggered the emergency Caesarean.
"When my wife saw the dip in the heart trace she hit the emergency button," Mr McCall said. "They dragged Amanda's bed out of the delivery room, trailing monitors, to the operating theatre where they did the Caesarean. They found a faint heartbeat [in Ebony] but there was no respiratory effort. They tried to resuscitate her for half an hour but it didn't work. By this time we were in bits."
Mr McCall said there were 13 deliveries during that shift, and four midwives and two trainees on duty. "The foetal heart traces should have been spotted as abnormal," he added. "But because everyone was so busy they were missed."
Earlier, at about 4pm, an ultrasound scan had shown Amanda's kidney was swollen; she only had one kidney because she lost the other as a child. Mr McCall said the urologist advised it would be best to deliver the baby. But Ebony was not delivered until 3am the next day. After Ebony's death, the McCalls complained to the hospital but the reply "glossed over" the key points, they felt. "Amanda is only young and she lives at home with us," Mr McCall went on. "She has still not come to terms with Ebony's death. She has split from her partner; it was just too much for them. If the hospital had acted sooner Ebony wouldn't be dead."
A spokesman for the Care Quality Commission, the NHS regulator which replaced the Healthcare Commission last April, said: "Milton Keynes is a maternity unit where there have been problems in the past. We are following up last year's report to review progress and we will be reporting our findings in due course."
Milton Keynes has one of the fastest growing birthrates in the country. There were 3,637 births in 2006-07. A spokesperson for Milton Keynes NHS Foundation Trust declined to comment.
Maternity units: Not enough midwives, even fewer consultants
Maternal and infant deaths in Britain are at record lows, but the consequences of errors can be catastrophic.
*A national inquiry into England's maternity services involving all 150 maternity units, published in July last year by the Healthcare Commission, revealed a critical shortage of midwives, obstetricians absent from wards, lack of beds and poor continuity of care. It said the problems had contributed to high death rates in some units and threatened the long-term health of mothers and babies in others.
*Only two-thirds of trusts had a consultant present on their wards for 40 hours a week, the basic safety standard laid down by the Royal College of Obstetricians.
*Many trusts were critically short of midwives, with numbers ranging from 40 per 1,000 births in the best-staffed trusts to 25 per 1,000 in the worst.
*The root cause of poor performance was weak leadership by managers and medical staff, the commission said.
*The national inquiry followed separate investigations at three trusts where mothers and babies died: Northwick Park Hospital in Harrow, where 10 mothers died between 2002 and 2005, New Cross in Wolverhampton, where three babies died in two months in 2003, and Ashford & St Peters in Surrey, where there was a series of serious incidents in 2000 and 2001.
*More than £660m was paid out by NHS trusts in the three years to 2007 in negligence cases for obstetric claims, enough to hire 1,000 extra consultant obstetricians.