The death of Ida Lock in November 2019 has brought to light severe failures in maternity care at the Royal Lancaster Infirmary.
Ida was born on 9 November 2019 but died a week later from brain injuries caused by a lack of oxygen.
The Coroner’s inquest revealed that her death had been caused by the midwives’ failure to deliver the infant “urgently when it was apparent she was in distress” and contributed to by the lead midwife’s “wholly incompetent failure to provide basic neonatal resuscitation”.
Missed opportunities and incompetent care
The Coroner found eight missed opportunities to change the course of Ida’s care.
The Coroner noted:
“Ida was a normal child whose death was caused by lack of oxygen during her delivery that occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress”.
This failure in the first few minutes of Ida’s life caused irreversible brain damage, contributing to her death.
A report from the independent Healthcare Safety Investigation Branch (HSIB) identified numerous failings in Ida’s care, including the failure to recognise an abnormally slow fetal heart rate.
Despite this, an internal hospital report praised the staff for “great cohesion and communication” in the delivery suite, showing a stark contrast to the reality of the situation.
The aftermath and inadequate investigations
The hospital’s response to Ida’s death was equally disappointing. Ida’s parents, Sarah Robinson and Ryan Lock, struggled to get answers.
They were told the midwives had demonstrated “excellent teamwork and had all worked in the best interests of mum and baby,” despite the clear failings.
Ryan Lock said:
“Our efforts to get any answers have been met with a complete block.”
The investigation into Ida’s death was described as “not worth the paper it was written on” by a midwife involved in the process.
Tabetha Darmon, the Chief Nursing Officer at the trust, issued a statement of regret, acknowledging that “we accept that we failed Ida and her family and if we had done some things differently and sooner, Ida would still be here today.”
She further stated:
“We also acknowledge the additional upset caused to Ida’s parents and family as a result of the way investigations into Ida’s death have been conducted since 2019.”
Tabetha said in a statement last week that they have made improvements since and are “carefully reviewing the learning identified to ensure that we do everything we can to prevent this from happening to another family”.
Lessons still unlearned
Ida’s case follows a pattern of failures at the Morecambe Bay NHS Trust. Between 2004 and 2013, a series of maternal and neonatal deaths occurred at Furness General Hospital, also run by the trust.
An investigation by Dr Bill Kirkup uncovered “substandard clinical skills” and a “dysfunctional culture” at the trust. Despite promises to improve, these issues continue to resurface.
Dr Kirkup, who also investigated the East Kent maternity services, has expressed frustration that “these issues continue to happen” even after previous inquiries.
Many of the issues he found – poor culture, weak teamwork, ignoring families, and failing to investigate or learn from incidents – mirrored those uncovered at Morecambe Bay seven years earlier.
He was forced once again to explain to families why they had been failed by a trust that didn’t know how to do the right thing.
The fact that improvements have been slow or non-existent raises serious concerns about whether the NHS can truly learn from past mistakes.
Comment
The failure to provide basic care, the lack of accountability, and the inability to learn from past mistakes is disappointing.
Ida’s parents hope other couples do not experience what has happened to them. But they know long before them, other families also suffered – and they aren’t confident that more won’t in the future.
Sarah says:
“Those families experienced what we’re going through now, but nothing changed. You can’t trust that improvements will ever happen.”
“I hope something does change”.
How can we help?
Yasmine Mirza is a Paralegal in our Medical Negligence team, which is ranked in Tier One by the independently researched publication, The Legal 500.
For advice on the subjects discussed in this article, please get in touch with Yasmine or another member of the team in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online enquiry form.
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