A coroner has sent a Prevention of Future Deaths report to a hospital Trust after ruling that lessons have to be learned from the death of a seven-day-old baby.

Amelia Barbosa died on December 13, 2020 due to complications during her delivery, and a coroner has asked for training and feedback for those involved in her case at Peterborough City Hospital, and also the wider hospital team.

Peterborough City Hospital is run by the North West Anglia NHS Foundation Trust and an investigation into Amelia's death was launched on October 14, 2021 and concluded at the end of her inquest on May 17, 2023.

At the inquest, the coroner concluded that Amelia died as a result of an acute hypoxic injury suffered in the period immediately before delivery, which continued during resuscitation, leading to hypoxic ischaemic encephalopathy.

The medical cause of death was: hypoxic ischaemic encepalopathy; and placental pathologies: acute chorioamnionitis and delayed vilious maturation.

Samantha Goward, assistant coroner for Cambridgeshire and Peterborough, made a number recommendations in her report, including training and feeback for staff involved in Amelia's case.

The inquest heard that Amelia’s mother had a routine pregnancy and was given a due date of December 1, 2020. She attended Peterborough City Hospital at around 10.30 hours on December 5.

Due to a failure to progress in the second stage of labour, and suspected fetal compromise, at around 0240 hours, a decision was made for a caesarean section delivery.

The coroner's report states: "There was some difficulty due to Amelia’s head being impacted, but the obstetrician and senior midwife worked together and this was resolved within four minutes.
"Due to difficulties siting a spinal anaesthetic, and Amelia’s head being impacted, the time from decision to delivery was 83 minutes.

"Expert evidence confirmed that, on the balance of probabilities, Amelia suffered an acute hypoxic insult commencing around 10 minutes before her delivery, which was ongoing during resuscitation."

Amelia was transferred to Addenbrooke’s Hospital where the extent of her injuries were confirmed and she sadly died on December 13, 2020.

The coroner's report said a number of issues were identified with resuscitation and the decision to take blood from a specific area of the baby's cord.

In her report, she said: "While I heard evidence that there has been training for midwives on how to take cord blood, and I was provided with a copy of a poster that was said to have been in use at the Trust for some time, in April 2023, over two years after this delivery, the midwife who gave evidence said that she and her colleagues were of the opinion that it was appropriate to take a sample from anywhere in the cord, not just in the clamped area.

"The expert and the Trust’s own head of midwifery advised that this was not appropriate. It therefore does not appear that the learning has been passed on to all Trust midwives and there is a risk that in future cases those treating a baby will be falsely reassured by normal cord pH results which may not be accurate."

She went on to say: "I am also concerned that there does not appear to have been training in relation to the provision of blood transfusions in such cases to ensure that all potential reversible causes are treated before resuscitation stops.

"The head of midwifery who attended the inquest to advise on issues relating to the recommendations was not in a position to provide evidence on the neonatal position and I have been provided with no evidence by the Trust that these issues have been considered. I am concerned that they require further action."

While in NICU, there was also a delay in Amelia being effectively cooled due to the active cooling machine not working, the coroner says she has been advised that this has now been replaced. 

The Trust has 56 days to respond to the coroner.