A twin baby boy died during a botched caesarean section at Lincoln County Hospital, which senior management stand accused of trying to cover up.
A report published by Coroner Stuart Fisher found that Thor Harrison Dalhaug died as a result of “unorthodox and unacceptable” methods used to delivery him via caesarean section in September 2013.
It was found that the surgeon carrying out the operation was on her first day at work and was unsupervised, despite the procedure being deemed complex due to it being twin delivery.
Unable to manually lift Thor’s head from the pelvis, the surgeon used the “unorthodox and unacceptable” method of forceps to try to free the baby, when a method of “vaginal push” should have instead been used. It was this practice which led to the baby suffering a major brain haemorrhage.
It was only when the use of forceps failed that a consultant was called and Thor was delivered five minutes later but was in a “poor condition”.
Despite efforts to resuscitate Thor, he died an hour after his birth. His twin brother was delivered shortly after Thor, in a healthy condition.
Mr Fisher, the coroner for Central Lincolnshire, raised a number of concerns in his report, which he said could put further lives at risk unless action is taken. Among them was an attempted cover-up by management at the United Lincolnshire Hospitals NHS Trust (ULHT).
As a result, Thor’s parents, Rolf and Michelle Dalhaug, of Grantham, have called for an independent investigation into the circumstances of Thor’s death.
Mr Dalhaug said: “The trust have acted appallingly, causing our family great hardship. We accept that accidents can, do and will happen. What we do not accept is their failure to be honest, their failure to learn and their failure to act.”
Mr Fisher’s concerns stated in the report are:
* The failure to supervise the operating surgeon on her first day at work for a complex twin delivery.
* The lack of steps taken to discipline the clinicians involved or limit their practice given their decision to adopt a wholly inappropriate, unacceptable and unorthodox technique in delivering Thor, resulting in his death.
* The failure to ensure a full contemporaneous record was kept by doctors involved in a term neonatal death. Mr Fisher wrote: “Such failure has seriously hampered my investigation into the circumstances surrounding Thor’s death and has resulted in serious difficulties to Thor’s family who clearly struggled and suffered as a result of not being able to understand why their son died shortly after his birth.”
* The failure to identify in the immediate aftermath of Thor’s death that the operating surgeons had neglected to make a full note of the circumstances in which he died. It was said that senior management dissuaded a clinician from reporting the fact that forceps were used due to concerns over how this would be perceived if the matter were to be investigated.
* The fact that the consultant ultimately responsible for Thor was also charged with undertaking the ‘Serious Untoward Incidents’ report into his death, furthermore having signed off the report without having read any of the statements referred to in that report.
* The fact that the report and the revised version completed after receipt of the post-mortem failed to disclose that there was no support for the use of forceps to disimpact the fetal head.
* The fact that no steps have been taken to discipline those involved in the production of the “wholly inadequate” report.
* The fact that none of the statements served by ULHT disclosed that there was no support for the use of forceps to disimpact the fetal head.
* The fact that there was a failure to recognise the inadequacy of the operating surgeon’s original statement and report, and that these inadequacies were not addressed until the coroner directed the ULHT to obtain a full statement and undertake a comprehensive report.
ULHT medical director Dr Suneil Kapadia said: “We are deeply sorry for the shortcomings in care provided to Thor’s mother and the tragic impact this has had upon Thor and his family. United Lincolnshire Hospitals NHS Trust has accepted liability for Thor’s death and will be working with the family’s solicitors to agree an appropriate compensation package.
“Following an internal investigation a detailed action plan was put in place to improve clinical practice at the trust. The healthcare inspector, the CQC, recently rated our maternity services as good and highlighted our good incident reporting culture and the positive changes that have been made over the last six months.
“We have learnt important lessons from this tragic case and have implemented changes to reduce the risk of anything similar happening again. We very much regret that these changes came too late for Thor and his family.
“We are considering all of the coroner’s recommendations, and will respond to the coroner by the specified deadline.”