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West Middlesex Hospital ordered to make improvements after delayed labour leads to death of baby

West Middlesex Hospital ordered to make improvements after delayed labour leads to death of baby

A heartbroken couple is urging the NHS trust behind West Middlesex Hospital to ensure lessons are learned after delays in labour caused the death of their baby.

Marzena and Grzegorz Michulec said they were left in "unimaginable pain" after the death of their baby, Zuzannah Bienias, who lived for just 36 minutes at West Middlesex Hospital in March 2016.

In March this year, an inquest held at West London Coroner’s Court into the Chelsea and Westminster Hospital NHS Foundation Trust discovered that Zuzannah died proximately after her delivery as a result of an infection which she developed because of a prolonged labour.

Zuzannah also suffered from head injuries and starvation of oxygen to the brain during her delivery.
David Thomas – a medical law expert for Simpson Millar, and the family’s lawyer, said: “This case is truly tragic and has left the family devastated.

“The inquest revealed that Zuzannah died from an infection due to delays in the labour that were not addressed quickly enough, as well as from head injuries sustained during delivery and starvation of oxygen to the brain – injuries that could have been avoided had the correct protocol been followed.

“It is now imperative that the lessons learned - as outlined in the Serious Incident Report by the Trust following the death of Zuzannah - are shared in order to ensure that such errors are not allowed to happen again.”

Ms Michulec arrived at West Middlesex Hospital on March 12, 2016, with contractions.

She was transferred to the Natural Birth Centre – however 12 hours later, her progression into labour was still slow which meant Ms Michulec was transferred to a Labour Ward.

Ms Michulec waited for one hour and 42 minutes for an epidural because the anesthetist was in theatre.

After a few more hours of prolonged labour, Ms Michulec was seen in theatre for assessment where it was found that Zuzannah’s head was stuck.

Although efforts were made to free Zuzannah’s head - medical staff were concerned about the lack of movement and, at this point, it was decided that an emergency C-section was needed.

Medical staff finally delivered Zuzannah, but she was unresponsive, floppy and blue and despite their efforts – medical staff were unable to resuscitate the baby.

Marzena Michulec said: “The whole experience was utterly traumatic for me and my family – the labour was really difficult, and to then lose my baby - it’s left me psychologically scarred.
“We trusted that everything was being done properly and I was being monitored correctly.

"Whilst it’s a step in the right direction that the Trust has recognised where it went wrong, I can only hope that the Trust truly learns from the mistakes and take action across the whole of the NHS, and ensures that this doesn’t happen again to anyone else.”

Both the inquest findings and serious incident report carried out by the Trust into the baby’s death identified a series of lessons that had to be learnt – which included the importance of undertaking a complete review when assessing delays in labour, the importance of reviewing patients better when they arrive in hospital, and taking a look at the technique used in the resuscitation.

The Trust will undertake new measures including reminding staff to look at the full clinical picture when assessing a delay in labour, a reflection with the midwife on the patient’s review when she first arrived to the hospital, and the discussion of using a different technique in resuscitation.

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