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Evening Standard
Evening Standard
Tristan Kirk

Premature baby dies after London mother waits 44 minutes for ambulance, coroner finds

A premature baby died after ambulance service blunders during his birth caused a 90-minute delay on him reaching a hospital, a coroner has found.

O’Shea Medad Dover was born at 30 weeks after mother Laura felt abdominal pains and called for an ambulance.

An inquest found the emergency call was “wrongly categorised”, causing a 44-minute delay in paramedics arriving to help.

At the scene, paramedics mistakenly believed the birth was imminent and did not rush her immediately to hospital.

In a report issued after the inquest, assistant coroner for North London Peter Straker found Laura could have been brought to hospital just before 9pm, but actually arrived at 10.30pm.

If she had been brought straight to hospital “it’s likely O’Shea would have survived”, he concluded.

“Midwifery advice was for the paramedics to bring Laura to hospital because pre-term deliveries require full obstetric and neonatal support,” he wrote in a report aimed at preventing future deaths.

They did not follow this advice because they thought Laura was soon to deliver – a conclusion they’d be less likely to have reached had the call been correctly categorised and they’d been with her 44 minutes earlier.“Extrication from the property was challenging. London Ambulance Service guidance told them not to extricate if delivery is thought to be imminent,” the report said.

Two midwives “recognised the seriousness of the situation” and came to Laura, the coroner said, and determined that she had a pregnancy complication known as placental abruption, rather than being about to give birth.

They helped paramedics transport Laura to an ambulance, but at 10.44pm there was no foetal heart rate.

“At 11.04pm O’Shea was delivered, resuscitation was started and caused a return of spontaneous circulation at 11.12,” said Mr Straker.

“Given these things, it is likely O’Shea was subjected to acute severe hypoxia between 10.14pm and 10.19pm.

“If the call to emergency services had been correctly categorised, Laura would have probably been in hospital by 8.57pm.”

The coroner added that the baby would have been monitored and an emergency caesarean could have been performed to save his life.

The coroner noted in his report that London Ambulance Service has now improved its guidance to say “where delivery is not progressing the patient should be conveyed to a hospital with obstetricsupport”.

He recommended that the new guidance is rolled out to emergency services across the country.

London Ambulance Service said paramedics followed guidelines in place at the time, to remain at the scene and call for midwifery assistance.

Dr Fenella Wrigley, Chief Medical Officer at London Ambulance Service, said: “On behalf of London Ambulance Service, I offer my sincere condolences to the family of O’Shea Dover and apologise wholeheartedly for the delay in arriving at the scene.”

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