The inquest into the death of a baby girl who lived for just 20 minutes after her birth at St Richards Hospital in Chichester has concluded that her death may have been avoided if a caesarian section had been performed earlier.
Leilani Chute, known as Lily, was born on 5 August 2015, weighing 6lbs 14oz at St Richards Hospital, part of the Western Sussex Hospitals NHS Trust. An investigation by the Trust, conducted a month after Lily’s death, documented numerous failings in respect of the treatment provided to Lily’s mother during her delivery and concluded that Lily had been starved of oxygen as a result of poor monitoring.
On Thursday 30 June at West Sussex Coroner’s Court, assistant coroner Bridget Dolan QC, concluded that the cause of Lily’s death was a hypoxic brain injury due to umbilical cord occlusion. However, she added that delivery should have been by caesarian section at 14:20, approximately 25 mins before actual delivery, thereby avoiding cord occlusion and acute hypoxic occlusion.
The coroner will now make a Prevention of Future Deaths report to the Trust in which they will be required to address a number of failings, including: a lack of consent policy specific to the obstetric department dealing with caesarian births. This relates to evidence that the obstetric registrar steered Lily’s mother towards a vaginal delivery and admitted not providing her with information on pros and cons and risks relating to a caesarian section, thereby depriving her of the choice of her delivery.
Lily’s mother, Katherine Chute, who was aged 28 at the time, went into labour in the early hours of 2 August. She had high blood pressure and was admitted to hospital when her contractions became more intense throughout the day at around 6pm. Shortly before midnight however, she was given the option to return home as her contractions had slowed down and her blood pressure was normal.
On returning to the hospital the next day at around 2pm, Mrs Chute was found to have high blood pressure but again was sent home, only to return to hospital again that evening as her contractions had increased.
The hospital advised Mrs Chute to remain so that she and her baby could be monitored. At around 4pm on 4 August, Mrs Chute was taken to the delivery suite to have her waters broken. The labour did not progress and Mrs Chute was seen by a plethora of different medical professionals between approximately 2am – 1pm on 5 August before being told she had to have a forceps delivery. Mrs Chute indicated that she wanted a caesarian delivery but was strongly advised against it.
Lily was delivered at 2:46pm by caesarian section and lived for 20 minutes after resuscitation attempts failed. Mrs Chute was given a general aesthetic shortly before the birth and was not aware of her daughter’s death until her mother told her later that day.
Lily’s parents were represented at the inquest by solicitor Andrew Harrison, a partner in the medical negligence team at Hodge Jones & Allen. Speaking on behalf of the family, he said: “Leilani lived the shortest of lives but will never be forgotten by her family. But for errors made in labour she would be with us today.
“We hope that valuable lessons will be learnt as a result of her death and the Inquest process. The Coroner will be writing to the Trust asking them to consider certain crucial clinical issues and we hope that they will undertake the further work diligently and rigorously so that no other family should have to suffer the pain and grief we have been through.
“We would like to thank the Assistant Coroner for her detailed investigation and her thorough findings of fact.”
Notes for Editors
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