On 11th November 2022, in Banbridge Courthouse, Coroner Dougan announced her verdict in respect of the stillbirth of Jaxon McVey on 26th May 2017, some 5 years and 7 months after the date of Jaxon’s death. Jaxon’s parents, Christine McCleery and Marty McVey were in court to hear the narrative accompanied by their solicitor, Patrick Mullarkey of O’Reilly Stewart Solicitors.
In finding that Jaxon had died when his birth became obstructed by reason of shoulder dystocia (the baby’s shoulder impeded delivery, becoming stuck on his mother’s pelvic bone), the Coroner made comprehensive findings on the basis of the evidence that she had heard during the course of the Inquest which proceeded before her for 5 days commencing 24th October 2022.
The Deceased’s death was both foreseeable and preventable. The Midwives responsible for the care of Christine McCleery, Jaxon’s mother, in the Freestanding Midwifery-led Unit in the Lagan Valley Hospital failed to identify the risk factors associated with a mother presenting with a BMI over 30 Kg/m2. Those risks include shoulder dystocia. Had they done so, then the risk of stillbirth would have been foreseen.
Furthermore had the risks of giving birth in the Freestanding Midwifery-led Unit been explained to Miss McCleery, and had the Trust’s Shoulder Dystocia Protocol (August 2011), NICE and RCOG Guidelines been applied, and a Risk Assessment performed, a referral would have been made for obstetric assessment. Likewise, had Miss McCleery been advised of the risk of shoulder dystocia which presented in her case, she would have elected, exercising her informed consent, to deliver under Consultant-led care. Had that been done, then Jaxon’s death would have been avoided.
In coming to that conclusion, the Coroner identified a number of missed opportunities in the care and treatment of Miss McCleery and the Deceased. There were, in short, a catalogue of errors, beginning with the measurement and recording of Miss McCleery’s height at the booking appointment in September 2016. This failure to correctly record the maternal height led to miscalculation in relation to antenatal growth throughout the course of the pregnancy.
In failing to ascertain the correct maternal height, the Midwife responsible for the care, Staff Midwife McIlwee, failed to identify a discrepancy between the referred maternal height, referenced in the GP referral letter, and the measure which she erroneously made. Failing to note the discrepancy, she failed to resolve it.
The significance of this failure was that had the correct height been recorded, and had the correct antenatal growth chart been plotted, the Deceased would have plotted twice over the 90th centile, which, according to NICE Guidelines, would have resulted in a referral for individual assessment, and which would have resulted, on balance, in a different outcome.
Irrespective of the error in the calculation of the maternal height, Miss McCleery’s BMI was over 30 in any event. This ought to have mandated a discussion between Miss McCleery and Staff Midwife McIlwee about referral to a Consultant Obstetrician due to the context of a planned delivery in a stand-alone Midwifery-led Unit. That discussion did not take place, and Miss McCleery was not advised of the risks.
Later during the course of the pregnancy, an assessment was made as to whether or not the Freestanding Midwifery-Led Unit remained a safe place for Miss McCleery to give birth. This assessment should have taken place at 36 weeks, but, in fact, took place at 37 weeks. The Coroner found, on the basis of the evidence, that that checklist was not explained in sufficient detail by Staff Midwife Mack, but particularly in relation to the reasons for transfer, and examples of obstetric emergencies, to ensure that an informed consent was taken from Miss McCleery. The Coroner found that had an appropriate discussion taken place, this too would have led to a different outcome for the Deceased.
When labour ultimately commenced, and when Miss McCleery attended the Freestanding Midwifery-led Unit for delivery, it is noted that the measures undertaken by the attending Midwives, Staff Midwife Topping and Staff Midwife Rankin, were not performed in a reasonable manner. Whilst it is likely that the McRoberts manoeuvre was performed correctly, it is unlikely that suprapubic pressure was applied correctly because of the lack of available staff in the Unit on the night in question. Whilst the Midwives were trained in measures to overcome shoulder dystocia, they did not have enough or sufficient experience to conduct those measures either correctly or effectively. Their training was lacking. There was a delay in calling the Ambulance when the shoulder dystocia was identified, and there was an earlier failure to correctly record the fetal heart.
Turning to overall management of the Unit, the Coroner identified further systemic failings on the part of the Trust which affected the safety of the delivery. The Midwifery-led Unit was comprised of small teams of Midwives, supposedly to ensure continuity of care, but there was no continuity of care for Miss McCleery who was seen by 9 different Midwives during the course of her pregnancy.
Knowledge of the Protocols and Policies relating to birthing within the Midwifery-led Unit was confusing, conflicting, and at times misinformed. Whilst the risk presented by a BMI of over 30 was known from at least 2011, that information did not appear to have made its way to the Midwifery staff prior to the events of 2017. The Coroner found that the Midwives within the Unit were unaware of the Shoulder Dystocia Policy which had been in place since 2011, and which specifically identified the risk. As a consequence of their lack of knowledge of that Protocol, they failed to assess Miss McCleery in accordance with same. Furthermore, the Trust Protocols are inconsistent with each other, and inconsistent with national Guidelines.
In a call to action by the Coroner, she noted that the Trust should review all Protocols and Guidelines to ensure consistency and clarity for Midwives and expectant mothers. Likewise, Coroner Dougan found that the Trust failed to circulate Guidelines, Protocols and Memos in an effective way to ensure that all midwifery staff understood their importance for application in their daily practice. Whilst the Strategy for maternity care in Northern Ireland 2012-2018 highlights the need for women being supported to make informed decisions about their place of birth, including being advised of the risks and benefits of place of birth, this did not occur in Miss McCleery’s case. The Guidelines operating within the Unit, relating to the eligibility for birthing within the Unit, failed to provide protection for women with a BMI over 30. Those Guidelines are inconsistent with UK wide Guidelines. As such, the Coroner found that the Guidelines failed to provide sufficient protection for expectant mothers. She found that a review of the Guidelines should be conducted.
There were insufficient experienced staff on duty in the Midwifery-led Unit to assist with the complications which arose in Miss McCleery’s case.
The Coroner concluded by noting that whilst there are no longer any Freestanding Midwifery-led Units open in Northern Ireland, (the Lagan Valley Freestanding Midwifery-led Unit having been suspended in 2022 due to safety concerns), a comprehensive review of the number of staff, experience, training and policies, should be conducted by the Department of Health in the event of these Units re-opening in the future.
