Arliya-Leigh Bull died at the age of 21 months, following a short lifetime of severe medical problems- Inquest found that there were missed opportunities to deliver Arliya-Leigh earlier
Nottingham Coroner’s Court has today (Friday, 22nd October) found that a baby’s death was due to natural causes following a number of missed opportunities to deliver her sooner, an inquest has heard.
Arliya-Leigh Bull was born on 5th February 2019 via an emergency caesarean section (c-section) at the Queen’s Medical Centre (QMC) in Nottingham, part of Nottingham University Hospitals (NUH) NHS Foundation Trust.
She was the second baby of mum, Laura Bagworth, who, during the pregnancy, was assigned to high-risk care due to a history of medical conditions, including spinal surgery, and was consultant-led throughout. Laura should have had an anaesthetic review during her pregnancy but this did not happen because the appointment letter was generated but never sent out by the hospital.
Prior to the baby’s birth, Laura had attended hospital repeatedly with various concerns such as reduced fetal movements. On the day of Arliya’s birth, Laura rang the labour suite at 4.06am, explaining that she was suffering with reduced fetal movements and painful, unusual contractions. She was told to get some breakfast, have a bath and make her way in later. However, HM Assistant Coroner Dr Elizabeth Didcock found that this advice was incorrect and Laura should have been told to come in immediately.
Laura arrived at hospital around 5.30am. A CTG was commenced at 5.42am which was abnormal from the start, but this was not recognised until around 6:45am.
There were difficulties administering a spinal epidural due to metalwork in Laura’s back from her previous surgery, which was documented within her medical records. This would have been picked up on the anaesthetic review, had that taken place. The Healthcare Safety Investigation Branch (HSIB) report found that this failure contributed to a further six-minute delay in delivery.
Arliya was born at 7.29am but needed ventilation and was found to have suffered a severe brain injury and multi-organ failure.
Arliya was not expected to survive due to the severity of her injuries but was able to go home with mum Laura after just a few weeks. She lived at home with her parents Laura and Reece, and older brothers Junior and Tyler.
On 15th October 2020, Arliya and Junior were staying overnight with a friend of Laura’s, who was also Arliya’s carer, when Arliya became unresponsive. Attempts were made to resuscitate her by emergency services, but Arliya sadly passed away upon arrival at QMC aged just 21 months.
At the three-day inquest into Arliya’s death, which concluded on 22nd October at Nottingham Coroner’s Court, HM Assistant Coroner Dr Elizabeth Didcock found that the CTG was miscategorised from the start. It should have been recognised and classified as abnormal at a much earlier stage. It was also accepted that when Laura telephoned the labour suite at 4.06am she should have been told to come straight in. If she had been, she would have arrived almost an hour earlier. The coroner found that but for the series of delays, baby Arliya would have been born by 6.10am.
Laura Bagworth, Arliya’s mum, said:
“When Arliya was born, we were told to prepare for the worst. But she defied all the odds and was able to come home with us six weeks later. She never stopped fighting until the day we sadly said goodbye. Arliya wasn’t just my daughter, she was my best friend and was loved by every single person who met her.
We miss her more and more every day, but I will forever be proud to be Arliya’s mum, she was an inspirational little girl who gave us so many incredible memories that will last for a lifetime.”
Baishali Clayton, inquest specialist and Senior Associate and Solicitor in our Medical Negligence team, and barrister Ross Beaton of 7 Bedford Row have been representing the family during the three-day hearing.
Baishali said:
“Arliya’s injuries were devastating and her premature death is simply heartbreaking. Nobody should have to say goodbye to their child. There were a number of missed opportunities during Laura’s labour, but the coroner could not determine that they would have made a difference to Arliya’s condition. Laura and Reece clearly adored their beautiful little girl and the coroner recognised that their care of her was exemplary despite her severe disabilities. We will continue to support Laura and Reece moving forward.”