Father gives final submission at fatal accident inquiry

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A grieving father has accused a health board of “systemic failures” that led to his daughter dying just four hours after she was born.

Nevaeh Stewart died three-and-a-half hours after she was born at Montrose Royal Infirmary’s community midwifery unit on September 30, 2012, despite the efforts of midwives based there and specialists who rushed from Dundee to her aid.

Her father Gary Stewart earlier described the unit as an “emergency response blackspot” during a fatal accident inquiry being held at Forfar Sheriff Court.

The inquiry earlier heard Nevaeh was born in a birthing pool at the Angus facility - but was immediately found to be “pale and floppy”.

An ambulance from Ninewells Hospital took almost two hours to arrive - with a sheriff blasting the “paucity of information” passed between midwives battling to save Nevaeh and a specialist team travelling to the unit.

Notes made by midwives showed they had noted a neonatal transport team as being “en-route” from Ninewells in Dundee at 5.40am - but didn’t arrive until 7.15am.

Mr Stewart was giving his final submission to the inquiry after 14 days of evidence from medical staff and 16 expert witnesses.

He said Nevaeh “did not have a chance she should have” because a 999-style response to the unit in emergency situations was not available - a situation rectified this year.

The inquiry heard transfer time to get sick babies to specialist units can run to several hours.

Mr Stewart said the standard of care given was “contributory to her death” and said NHS Tayside had failed to maintain satisfactory levels of communication between staff, failed to inform the family of potential delays in specialists reaching Montrose midwife unit and failed to implement the emergency neonatal transport system following expert recommendations in 2011.

He said: “I believe that if NHS Tayside told parents the truth about transfer times we would have made a different decision on obstetric care and we would have had timely access to specialist medical assistance if it was needed.”

Nevaeh mother, Mrs Kimberly Stewart, added: “Had I been told in 2008 when I was pregnant with our second child that I’d have to wait an unlimited amount of time for specialist help if something went wrong with the birth, or after the birth, I think that’s enough information - and as a mother-of-one, and for the baby, I wouldn’t have risked it.”

However, fiscal depute Andrew Hanton told the probe he believed the evidence “did not highlight a systemic failure, rather the challenges of running a health service in the 21st century.”

He added: “This was a tragic outcome that was unique in the careers of the midwives involved.

“None were able to identify changes that could have possibly prevented, let alone probably prevented, Nevaeh’s death.”

Sheriff Pino di Emidio said he would give a written judgement in due course.

Kimberly, 31, earlier told the inquiry told how she went into labour at her home in Auchenblae, Aberdeenshire, on September 29 2012.

She went to the maternity unit in Montrose - staffed only by midwives with no doctors on hand - where she had planned to give birth in a pool having had her previous three children at the unit.

But when Nevaeh, the family’s fourth child, was born she was said to be “pale” and was immediately rushed into another room for treatment.

Kimberly was told to have a shower by midwives before a doctor entered the birthing room a short time later and asked her if she wanted to sign a do not resuscitate order.

Kimberly said she had been given just one chance to hold Nevaeh before she was taken away by midwives.

Both she and her husband, Gary, 30, criticised the emergency response available to mothers at community maternity units.

Kimberly said: “I think from my experience given the face that this happened with my fourth time where I’m deemed to be an old hand at the birthing thing, I don’t think you can ever determine a pregnancy is low risk. You never know what is going to happen.

“I think a blue light ambulance should have been called straight away. That’s the quickest way to get help.”

Giving evidence himself as a witness, Mr Stewart, 30, said the family had later discovered that a neo-natal transfer unit can take “several hours” to arrive at midwife led maternity units.

He said: “It seems that the NHS are of the opinion that community midwife units are emergency response blackspots.

“I presumed that if there was an emergency an emergency response team - a flying squad - would be brought in to fix the situation.

“I think the expression used was that they would ‘weech’ us down to Ninewells if there was a problem.

“If you have a home birth you can get a 999 response.

“The exception is in community midwife units where there is no emergency response and you may have to wait up to six hours as there is no emergency squad to go to any unit in Scotland.”