999 ambulance transfer to Ninewells might have avoided death of newborn

The entrance to A&E in Ninewells

The death of a baby born in a community midwife unit might have been avoided if a 999 ambulance transfer to hospital had been provided, a Sheriff has found.

Nevaeh Stewart was born unexpectedly unwell at 5.10am on September 30, 2012 at the Community Maternity Unit (CMU) at Montrose Royal Infirmary in Montrose, Angus.

Her condition deteriorated and she died there around three-and-a-half hours later, before she could be transferred to Ninewells Hospital in Dundee for specialist treatment.

In his findings, issued following a fatal accident inquiry in Forfar, Sheriff Pino Di Emidio said that the neonatal transport arrangements were “inadequate”.

He said the infant “simply languished” at the Montrose CMU with only the basic resuscitation care that could be provided by the midwives who “did their best in the circumstances”.

He outlined a number of precautions through which the death could have been avoided, including the provision of a 999 ambulance for retrieval of babies born unexpectedly unwell in the CMU.

As of 30 September 2012, there was no dedicated “flying squad” for the emergency retrieval of sick infants born unexpectedly unwell in a remote CMU to take them to Ninewells.

A dedicated neonatal transport rota team would normally be used to retrieve them, and if it was not available one from another area might be used, or an ad hoc team put together.

However babies born unexpectedly unwell at home in the area served by NHS Tayside (NHST) were transported to Ninewells by 999 ambulance.

When Nevaeh was born, the specialist neonatal ambulance which covered Ninewells was in Wick so medical staff had to make other arrangements to transfer her to hospital.

At about 05.45 hours an ambulance transfer was requested but when it arrived it didn’t have an incubator and a second ambulance was called, arriving at around 6.35am.

The little girl’s condition was deteriorating and when the neonatal transport team arrived at 7.15am advanced life support was started straight away, however she was pronounced dead at 8.35am.

In his findings, the sheriff said: “The reasonable precaution that would have avoided the death would have been to have had a 999 ambulance option as one of the primary options available for use to the consultant paediatrician who had the lead in dealing with the urgent situation that had arisen in Montrose CMU.”

The Sheriff also said: “Although none of the experts could say that N would have survived in the longer term if she had had prompter specialist treatment, she might have done.”

No births have taken place at the Montrose CMU since June 2016 when it was closed for births due to staffing shortages.

Professor Andrew Russell, medical director at NHS Tayside, said: “On behalf of NHS Tayside, I would wish to say that our thoughts remain with Nevaeh’s parents and family. We can only imagine how upsetting this continues to be for them and we are sorry for their ongoing distress.

“We will be taking the time to carefully consider today’s determination and the recommendations outlined in the report.

“Sheriff Di Emidio has acknowledged in his determination that we have made a number of changes since 2012.

“This includes updating the guidance on the use of a 999 ambulance for the retrieval of babies born unexpectedly unwell in community maternity units.”