Orpington hospital's 'lack of leadership' contributes to baby's death

On June 23, 2021, Ruth and Martin Kennedy's first baby, Finn, was born at the Oasis Birth Centre - a midwife-led unit within the Princess Royal University Hospital in Orpington.

During labour, Finn experienced a significant hypoxic-ischemic encephalopathy (HIE) and was taken to King's College Hospital NICU for treatment.

HIE is caused when a baby’s supply of oxygen is interrupted during birth and the lack of oxygen can lead to a brain injury.

On July 1, 2021, just eight days after he was born, Finn died after the life support machine was switched off.

At an inquest on Thursday, April 25, Senior Coroner Dr Julian Morris concluded that a “lack of leadership” contributed to Finn’s death, but he did not class it as “neglect”.

Speaking to the News Shopper, parents Ruth and Martin said they want individuals in management to “take accountability”.

Ruth, Martin and baby Finn (Image: Ruth and Martin Kennedy)

Martin said: “There’s zero accountability and they just say they’re ‘sorry again’.

"I work in construction – if somebody dies on site, it’s shut, and there’s an investigation as soon as possible.

"The company directors who are responsible of that site can be put in prison.

“In this instance, this is the health service – it doesn’t make sense that it’s one rule for private companies and another rule for public services."

Who was in charge at the birth centre?

In order to offer a conclusion into Finn’s death, several issues were required to be “broken down” for further review, Senior Coroner Dr Julian Morris said.

The issues included understanding who was in charge at the birth centre; if Finn’s heartrate was correctly monitored; if there were adequate staffing levels; and whether there was neglect.

The evidence provided at court indicated that two staff members were in charge, with one being a student midwife.

In response, Dr Morris said that this scenario "could not be the case," emphasizing the need for someone to take "overall responsibility.”

It was mentioned that, setting aside issues concerning whether a student midwife should be present as Ruth and Martin did not want that, there was no evidence indicating that anyone took control.

It was reported that, upon consideration, neither of the staff members were deemed to be in charge, and both relied on each other.

At the hearing, Dr Morris said: “The overall lack of leadership on ward, in the centre, and in the room, contributed to the sad events”.

Was Finn’s heartrate correctly monitored?

It was reported that at 7.10pm, during the second stage of labour when Ruth was fully dilated, the frequency of monitoring Finn’s heart should have increased to every five minutes.

Dr Morris confirmed that over a two hour period, there should have been 24 readings, however only eight readings were recorded, with many lasting for less than one minute.

Evidence provided by the student midwife indicated she was unaware of the increased monitoring; however, the other midwives did not implement the regime.

It was explained to the court that Finn's heart rate was difficult to hear, but the midwives did not persuade Ruth to come out of the pool where she would be giving birth.

The Coroner found that the lack of evidence contributed to his poor condition at birth.

Were there adequate staffing levels?

Dr Morris concluded that it has been “clear from evidence that closure rates have increased”, since the death of baby Finn.

“Whilst delays are unfortunate, I do not think it contributed to his poor condition”, Dr Morris said.

Dr Morris concluded that he did not think the staffing levels contributed to Finn’s poor condition.

Was there was neglect?

Dr Morris said that neglect in this context means “failure of adequate knowledge from someone in a dependent position”.

The family claim the foetal heart monitoring was not conducted.

The trust disagreed, as midwives gave evidence that they tried to monitor, but that it was difficult.

Dr Julian Morris said: “In balance, I am persuaded by the trust argument.

“It was the frequency which contributed to Finn’s condition.

“Whilst I have concluded there were failures in the birth, the failures required close monitoring and not in my opinion neglect.”

Dr Morris concluded that Finn’s cause of death was Hypoxic Ischaemic Encephalopathy with a delay in delivery during the second stage of labour.

Dr Morris said it was “fair to say on balance” the trust had addressed the identified issues and was managing on a day-to-day basis.

Consequently, Dr Morris said he will not be issuing a prevention of further death report and will instead write to the regional manager about the issues.

At the end of the hearing Dr Morris said: “Mr and Mrs Kennedy, I can only begin to understand the full extent of what you went through in 2021; to relive again in 2024 must have been extremely difficult.”

Parents of baby Finn, Ruth, and Martin Kennedy told the News Shopper that they want individuals in management to “take accountability” and are “disappointed” that they did not get the conclusion of neglect.

Ruth said: “It’s something that we have to deal with and accept, but it’s hard to accept.

“It’s really uncommon for neglect to be given as a conclusion – but it seems to be that they can substandard care that they do just enough to get away with it”.

Tracey Carter, Chief Nurse & Executive Director of Midwifery for King’s College Hospital NHS Foundation Trust said they “fully accept” the findings and would like to “apologise again” to the Kennedy family for the serious failings in care they experienced at King’s.

She said: “We fully accept the Coroner’s findings announced today, and we would like to apologise again to the Kennedy family for the serious failings in care they experienced at King’s.

“In recent years, we have made positive changes to maternity services at the Trust, including a review of midwifery staffing, enhanced training for midwives and ensuring more senior supervision in the department at all times.”