Baby died following mismanaged breech birth at Surrey hospital

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Taz Ali9 March 2021

A baby boy died during a breech birth due to delays and management issues at a Surrey hospital.

Midwives at Frimley Park Hospital failed to detect baby Theo Ellis was in the breech position – bottom or feet first in the womb – until his mother Laura Ellis was well into labour.

The hospital apologised to Theo’s parents for its failings in care and said it has made a number of changes.

Mrs Ellis and her husband James Ellis, from Bagshot, Surrey, said they are speaking out after the death of their first baby because they “don’t want anyone else to be failed so badly”.

A report by the Hospital Safety Investigation Board (HSIB) found the hospital did not carry out admission checks that may have found whether the baby was in the breech position.

When the breech position was later identified it was not declared as an emergency.

A consultant was not available on site to manage the birth, contrary to Royal College guidance.

Attempts to resuscitate Theo after he was born were foiled after the oxygen cylinder in the resuscitation equipment ran out.

A serious incident review was subsequently held by the hospital following Theo’s death in April 2019.

Mrs Ellis said: “We are speaking out about Theo’s death and what happened to us because we don’t want anyone else to be failed so badly, and have their child die.

“We don’t want anyone else to have to live with the unbearable pain and grief that we have endured.

“We would like assurances that staffing levels have been improved and will be maintained in line with national standards.

“All families whose children will be born at Frimley Park need to be assured that training is at national standards, that staff work as a team, and that equipment is always maintained to meet any eventuality.”

Leigh Day solicitors, who are representing Theo’s parents after they brought legal action against the hospital, said his death was declared a stillbirth, which meant a coroner was not able to hold an inquest.

Leigh Day solicitor Fiona Huddleston said: “It is a relief to our clients that Frimley Health NHS Foundation Trust has admitted liability for the appalling treatment that Laura endured and for the errors that occurred during the delivery of their baby, Theo.

“They hope that in telling their story, Frimley Park Hospital will address the issues that have been highlighted in respect of the safety of maternity care at their hospital.”

A spokesman from Frimley Health Foundation Trust said: “This is a tragic case and we are very sorry that our care for Mrs Ellis and baby Theo failed to meet the standards we expect of our maternity services.

“We have fully accepted and taken on board the findings and recommendations in the investigation report carried out by the HSIB, and we met with Mr and Mrs Ellis to express our condolences for their sad loss and to apologise for the trust’s failings in care.

“We have discussed the findings of the HSIB report with Mr and Mrs Ellis and shared with them the steps that we have taken aimed at preventing anything like this happening again.”

The trust said a number of changes have been implemented including a full emergency response whenever a baby is found to be in breech position and a consultant obstetrician present for all breech births.

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