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Rachael Gourley secures neglect finding for family in neonatal death inquest

26th January 2022

Rachael Gourley acted for the family of Baby SH who tragically died hours after her birth in December 2019. The inquest lasted three days and considered the care and treatment of Baby SH’s mother on the Maternity Assessment Unit and in the delivery suite, as well as the circumstances of Baby SH’s delivery.

A plan was made by the Consultant to trial instrumental delivery if Baby SH’s head was low, otherwise a caesarean section was to be performed. This plan was not followed by the Registrar, who attempted instrumental delivery despite Baby SH’s head being mid-cavity and her being in the occupit posterior position. Unsuitable (Wrigley’s) forceps were also used in the instrumental delivery causing Baby SH to sustain a skull fracture.

The Coroner returned a narrative conclusion that Baby SH’s death was “contributed to by neglect.” The Coroner considered that proceeding to deliver Baby SH using forceps manifestly unsuitable for vaginal delivery, and without any attempt to rotate her head, was a failure to provide Baby SH with basic medical attention.

In the Coroner’s summing up, he expressed his view that this was “a wholly preventable death.”

Rachael acted pro bono and was instructed by Natalie Fox and Rosie Booth at Irwin Mitchell.

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