Abstract
An inquest was held into the death of Ellis Hurndall, born on 6 February 2005. On 5 February 2005, Ellis's mother, Mrs Hurndall went into labour and was admitted to North Manchester General Hospital. CTG monitoring of the fetal heart was commenced at 23:30 until 00:20 on 6 February 2005, then from 02:30 until 11:45 when it was discontinued.
At 04:15, Mrs Hurndall was administered with intravenous syntocinon, a drug used to stimulate labour by encouraging efficient contractions. The infusion of syntocinon was initially commenced at 3 mL/hour but was subsequently increased throughout the labour: first to 6 mL, then 12 mL, 24 mL and finally to 48 mL.
A trial of pushing was commenced at 10:00, but the head did not advance very well. A trial of ventouse was recommended with a view to proceeding to Caesarean section if unsuccessful. At 11:45, the CTG was discontinued when Mrs Hurndall was transferred to theatre. At 12:00 the syntocinon was further increased to 60 mLs per hour on the basis that Mrs Hurndall's contractions were diminishing. The ventouse cup was then applied but the attempted delivery was unsuccessful, and at 12:13 it was determined that she should undergo an emergency Caesarean section. Uterine rupture was then noted: as a result Ellis's oxygen supply had been compromised, but due to the failure to continue fetal monitoring the inevitable fetal distress resulting from the uterine rupture had not been noticed or acted upon. At 12:30, Ellis was delivered with no sign of any movement and was very flat. He was intubated and ultimately transferred to the Special Care Baby Unit. Ellis was subsequently diagnosed as having quadriplegic cerebral palsy. He had no gag reflex and had to be gastrostomy fed. Ellis died on 3 December 2005, aged 9 months.
An inquest was held at Rochdale Coroner's Court in February and March 2008. The cause of death was found to be: (1) pneumonia; (2) absent gag reflex; and (3) hypoxic ischaemic encephelopathy following ruptured maternal uterus. The Coroner found that a fetal heart abnormality is often the first sign that a uterine rupture is occurring and that such abnormalities are more likely when syntocinon is being used to stimulate the labour. The Coroner found as a fact that there had been no fetal monitoring following Mrs Hurndall's transfer to theatre at 11:45 and that appropriate monitoring would have led to a much more prompt realization of Ellis's compromise following uterine rupture.
The Coroner was invited by the family's solicitor to consider a verdict of natural causes coupled with a rider of neglect. It was submitted that the failure to monitor the fetal heart constituted a ‘gross failure’ following the definition of neglect in R v North Humberside Coroner ex parte Jamieson [1995] QB 1 and the findings of Moses J in R (On the application of Davies) v HM Coroner for Birmingham [2003] EWCA Civ 1739. The Coroner agreed and found that, but for the failure to monitor, Ellis's life would have been prolonged: ‘The manner in which Ellis came by his death is also a rarity. This is the first case of its kind that I have dealt with but such deaths ought not to happen and the extent of his brain damage similarly points strongly to a gross failure of care. The team caring for Ellis should have realized the need for action in all the circumstances and the failure to monitor the fetal heart rate is in my view a gross failure, but for that failure to take action Ellis's life would have been prolonged.’
A verdict of death due to natural causes to which neglect contributed was therefore brought in.