Barrow hospital trust apologises to parents of baby who died at five days old

Sascha Wells, director of midwifery, gynaecology and obstetrics, for the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT), said sorry to Poppy Rushton's parents Michael and Kayleigh on the final day of the inquest into their daughter's death.

Speaking on day five of the inquest at Cockermouth Coroners' Court yesterday (19), she said: "I'm apologising for the failures in midwifery care that Kayleigh received".

Poppy passed away in March 2016 at Burnley General Hospital, where she had been transferred from Furness General Hospital, which is run by UHMBT.

Ms Wells admitted she had concerns about maternity care when she started work at the Barrow hospital in 2011.

She said: "I don't believe we were providing the best care", especially over "accountability and responsibility".

Poppy's family's barrister Nicholas Peacock, speaking at the inquest, asked Ms Wells if maternity care at FGH had been safe.

She replied that the families who had previously lost babies "would say we weren't and I'd agree with them in those cases".

"I couldn't suspend maternity services, we had a community that needed it in place," she added.

Ms Wells admitted she had "significant concerns" about the care provided by senior midwife Lindsey Biggs, who was sacked by the trust following the death of Poppy and another baby in 2008.

She said Ms Biggs had not met the Nursing and Midwifery Council's (NMC) code of conduct during Poppy's birth, adding "I made the decision to suspend her without prejudice" pending an investigation.

The director was also asked whether Ms Biggs should have used a stethoscope, instead of her fingers, to check the baby's heart rate.

"Our guidance is very clear," she said. "The best practice is to use a stethoscope. She didn't follow that guidance."

Ms Wells told the inquest she had met with Poppy's parents on several occasions after her death and "informed them of my concerns". She agreed there had been poor communication with the family during the incident.

Asked by Mr Peacock if this incident would be a one off, she said: "I hope so".

Ms Wells was then asked if she was aware Ms Biggs was under investigation by the NMC at the time of Poppy's death.

"I was made aware of a lot of things I hadn't been aware of prior to my appointment," said Ms Wells.

"She wasn't the only one who had been referred to the NMC."

She added that the NMC "were investigating" a previous incident involving Ms Biggs but "had not placed sanctions or restrictions on her practice".

Ms Wells said: "Therefore as her employer I had no opportunity to place sanctions".

She said, in her time with the trust, there had been "no clinical concerns" over Ms Biggs.

Since Poppy's death, Ms Wells said the trust had made a number of changes, including introducing the K2 Medical Systems electronic e-learning system. She said this was compulsory, "more robust and in depth".

"We are working at the national level to try and improve the training all midwife and obstetricians get", she added.

She also said: "We're constantly wanting to improve maternity services" and "to provide safe, high quality care".

Area coroner Kally Cheema also heard written evidence from Dr Meera Lama, a consultant paediatrician, and Professor Simon Mitchell, a consultant obstetrician and gynaecologist.

Dr Lama, who works at Burnley General Hospital, told the inquest Poppy's "long term outcome" had been "very poor", with a "high risk of disability".

The doctor said her parents felt strongly about the poor quality of life she would have and, after frequent discussions with the parents, the decision was "made to discontinue her intensive care".

She was baptised while on the unit.

Professor Mitchell's report said Poppy's "prognosis for recovery was extremely poor" and it was "unlikely to be in her best interests".

He said her poor condition at birth was "likely to have been due to cord compression" and he didn't think the outcome would have been different if there had been "quicker resuscitation" after birth.

The coroner has now heard all of the evidence and will give her decision and conclusion on Tuesday February 6 at 1pm.

The inquest in full

THE inquest into the death of a baby Poppy this week heard the "heartbreaking" details of her birth.

Much of the inquest into her case focused around the time shortly before and after her birth.

Poppy was born on March 2 2016 at Furness General Hospital, but passed away on March 8 at Burnley General Hospital.

Midwives Cassandra Calderbank and Lindsey Biggs described how Poppy appeared stunned when she was born.

Ms Calderbank said: "I didn’t have any concerns when her head was born. We had no idea of the condition she was about to be born in. When she came out she had a good tone and made attempts at breathing.

"I have delivered babies that are just stunned and then take a deep breath and start crying. She was just trying to get her breath and it never happened.

"She had a stunned look on her face and was moving her eyes around. She was really trying.

"It was a very amazing moment having a little girl be born and I was saying 'come on little girl, come on'."

After telling Mrs Calderbank to cut the cord, Ms Biggs began giving Poppy inflation breaths, before rushing her to the resuscitation room.

Ms Biggs said: "She just wouldn’t cry so I lifted her up.

"Her eyes were open and I remember saying to her that I could see her peeking at us.

"I just wanted her to give us a big cry. She was really trying to breathe. I needed to get her to breathe."

Others, however, said Poppy looked "lifeless and floppy".

Dr Chishinge, night junior doctor when Poppy was born, said: "When I got to the labour ward she was about four or five minutes old and I was told they were taking Poppy to the treatment room. One of the midwives was carrying her.

"I could see her in the midwife’s arms and when she was put on the resuscitation table I was very surprised by how she looked. She looked lifeless.

"She was very floppy and the colour was not good. She was very pale and there was no activity. Poppy was not moving or breathing. She appeared lifeless, that was my initial assessment.

"With experience you learn to assess babies just by looking at them at first. I knew she was very ill."

Later in the week, Derek Tuffnell, consultant obstetrician and gynaecologist, told the inquest he believed the midwives were monitoring the heart rate of Kayleigh Rushton, instead of her baby, in the 20 minutes before birth.

Dr Adam Gornall was asked to provide an expert report into the death of Barrow baby Poppy Rushton by the University Hospitals of Morecambe Bay NHS Foundation Trust.

Had Poppy been delivered 20 to 30 minutes sooner, he told the inquest: "Poppy probably would have required resuscitation but, on the balance of probabilities, would have survived".

Giving his evidence to the inquest, David Walker, medical director for UHMBT, sent his "sincere condolences" to Poppy's parents, calling the incident "heartbreaking".

Family's anger

POPPY'S parents, Michael and Kayleigh Rushton, earlier spoke of their anger at hearing the midwife in charge on the night was under investigation after another baby's death.

The devastated family criticised the "chaos" during her labour and said there was a lack of communication from midwives Cassandra Calderbank and Lindsey Biggs.

Mrs Rushton, 29, who works as a paediatric nurse at FGH, said: "We feel the care given to Poppy fell woefully short of what should have been expected.

"Her chances of survival may have been increased if better care had been given, especially the resuscitation and the chaos that surrounded it.

"We are very upset and devastated by our beautiful daughter passing away and we are very angry to learn about the failures and that Lindsey Biggs was allowed to continue in her role while being investigated for her part in another baby's death several years earlier."

The Barrow family described Poppy as "purple and limp" when she was born.

Mrs Rushton said: "Poppy was born and placed on my chest. I didn’t know there was anything to be concerned about. I didn’t worry at all or panic.

"She was purple and limp and I knew then something was wrong. She felt like a dead weight placed on me.

"Mrs Calderbank asked if the dad wanted to cut the cord but she was quickly told to cut it herself then Ms Biggs took Poppy from me. I couldn’t see what she was doing but I assumed she was giving her oxygen.

"She left the room with her and I told Mike to follow them."

Father Michael Rushton said the two midwives didn't explain what was happening to his daughter.

He said: "I gathered from the discussions between everyone that there was something wrong but no one explained anything to us. We were just reassured."Poppy was grey and purple and unresponsive. The cord was around her neck, not tightly but not loosely either."

The family issued a statement after giving evidence on day one of the inquest this week.

Mrs Rushton said: "Our family are absolutely devastated by the loss of our beautiful daughter Poppy, which has been as awful as any parent would imagine.

"We have seen lots of different reports regarding Poppy's death and hope the Coroner's independent investigation will help to give us clarity surrounding the circumstances in which Poppy passed away.

"We ask that people respect our privacy at this very difficult time."

Coroner hears evidence from midwives and hospital bosses

LEADING the inquest, area coroner Kally Cheema called on a range of witnesses to give evidence about the death of the five-day-old baby.

The inquest was held at Cockermouth Coroner's Court this week.

It started by hearing from Poppy's parents, Kayleigh and Michael Rushton, on Monday morning, before Sunday Ajayi, consultant obstetrician and gynaecolost at FGH, and Dr Victor Morris, locum consultant paediatrician gave their evidence.

Dominic Chishinge, night junior doctor, who attended the resuscitation room with Dr Morris, was called on Tuesday, before midwife Cassandra Calderbank spoke about delivering Poppy.

On Wednesday, Lindsey Biggs told the inquest she refused to participate into the Nursing and Midwifery Council's investigation into Poppy's death, despite knowing she would be struck off.

She was already under investigation after the death of Joshua Titcombe in 2008.

Ms Biggs returned to finish her evidence on Thursday, before the inquest heard from Dr Ashutosh Kale, a consultant paediatrician at FGH, and David Walker, medical director for University Hospitals of Morecambe Bay NHS Foundation Trust.

Expert witnesses Adam Gornall and Derek Tuffnell were also called during the inquest.

On Friday, Sascha Wells, director of midwifery, gynaecology and obsterics for UHMBT, apologised to Poppy's parents.