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Case Study: Stockport NHS Foundation Trust failings led to babies’ death at 24 minutes of age

Clarke Willmott were instructed by our client (B) to investigate a claim for clinical negligence following the tragic death of her son (X) at only 24 minutes of age.

As part of Baby Loss Awareness Week, Senior Associate Vanessa Harris discusses the case in more detail in the video below.


B maintained good health and fitness throughout the pregnancy of her first child B. She attended regular appointments and GROW scans at 29 weeks, 31 weeks and 34 weeks, all indicating that X’s size was on or around the 95th centile. Unfortunately, these had been plotted using an incorrect estimated date of delivery meaning that the charts were incorrect. At 36 weeks, a different midwife correctly adjusted the delivery date and noted a significant decrease in growth velocity, placing X in or around the 10th centile. A subsequent growth scan confirmed this new assessment.

At 40 weeks + 6 days of pregnancy, B became concerned that X was not moving as much as he had previously. She called the hospital and was advised to attend the maternity unit. A CTG scan was undertaken but due to an error with the machine, this had to be restarted. The results of the CTG were concerning, and she was advised that she needed to return for induction of labour the following day.

The following morning, B called the unit and mentioned that the foetal movements were the same as the day before. She was advised that the unit was very busy and that there were no beds available, and that she should call back at midday. However, when B called at midday there were still no beds available. At this point, the foetal movements were reduced but still like the previous day. She was told to call back in 3 hours. She called at 3pm and was told the Midwife would call her back with a specific time to come into the unit, with the promise that she would be called by 6pm.

At 6pm, after still not receiving a call, B decided to call the maternity unit again. This time she was notified that she had actually been missed off the call list and that she should come to the hospital. Around 7pm B arrived, but as no one was at the unit, she had to wait outside for 20 minutes. She was eventually booked in and told a midwife would come to review her, but nobody came. Around an hour and a half later a midwifery assistant finally came and took basic observations. At almost midnight a Midwife started CTG monitoring. Around an hour later vaginal examination was performed. There were possible shallow decelerations and no clear accelerations on the CTG scan at this stage.

Induction was commenced and Prostin gel was inserted in order to start the labour. A further CTG was undertaken which showed normal variability and no accelerations. B was in a lot of pain and was eventually given Pethidine. She immediately started vomiting and a further CTG was undertaken. The CTG was not consistently recording the foetal heart and the Midwife was unable to differentiate the foetal pulse from the maternal pulse. At this stage there was a shift change and another Midwife looked at the CTG and advised that it was concerning and requested Obstetric review. When the obstetrician attended, B was taken for an emergency caesarean section.

Tragically, when X was delivered, the umbilical cord was wrapped very tightly around his neck multiple times. Resuscitation was attempted but was sadly, unsuccessful. X was pronounced dead at just 24 minutes of life.

The Outcome

We instructed experts in the fields of midwifery, obstetrics and gynaecology and psychology. The Consultant Psychologist confirmed that because of the negligence, B had suffered depression and perinatal PTSD as a result of the traumatic birth and X’s death.

The Defendant Trust accepted that they had acted in breach of their duty of care in relation to the growth scans, in failing to admit B earlier and in their interpretation of the various CTG traces. They also accepted that had B received appropriate care then, on the balance of probabilities, X would have survived.

The Trust wrote a letter of apology to B and the parties entered into settlement negotiations. B ultimately accepted an offer of £60,000 in full and final settlement of her claim.

For more information on stillbirth or other medical negligence claims please contact our specialist team on 0800 316 8892.


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