Baby died after being 'starved' of oxygen during home birth following delay in being ...

Source: , Posted On:   16 March 2023

A newborn baby died after being 'starved' of oxygen during a home birth following a delay in being transferred to the hospital. Baby Arthur was an undiagnosed footling breech, where one or both of the baby's feet come first during delivery, and he became stuck during a planned home delivery in May 2021.

By the time mum Stephanie Trott was transferred to hospital, Arthur had suffered an irrecoverable hypoxic brain injury and his life support was withdrawn three days after his birth. At an inquest into his death in November 2022, the coroner concluded that the South East Coast Ambulance NHS Foundation Trust's delay in transferring Arthur and his mum to Princess Royal Hospital in West Sussex materially contributed to his death.

Parents Stephanie, 33, and Matt, 37, who have since had a baby girl named Primrose, are now fighting to raise awareness of the signs of breech babies in a bid to save another family's heartbreak. Stephanie, from Burgess Hill, just south of London said: "Life without Arthur is very painful – there is a real gap in our family where he should be and it will forever feel like a part of us is missing.


"He dominates our life and we are constantly thinking about him," she said. "My pregnancy was very straightforward – I seemed to glide through it. Everyone told me how much pregnancy suited me and no problems cropped up along the way. As I was classed as low-risk and we live less than 10 minutes away from our local hospital, I decided to have a home birth.

"I’d done a lot of research into hypnobirthing and I thought I could be more relaxed in a familiar environment. On the day of Arthur’s birth, I woke up in the early hours of the morning with a cramping tummy ache and knew something was happening. We rang the Princess Royal Hospital so we were on their radar, which is the case with planned homebirths.

"My mum was with me at the time because we were living in my parents’ annex. She kept saying how close together the contractions were – there was no break or lull in-between. I started to push and that is when a foot emerged so Matt phoned 999."

By the time they had arrived at the Princess Royal Hospital in West Sussex, Arthur was white and floppy (Image: Getty Images)

When paramedics arrived at 5.45am, Arthur’s feet were delivered. At 5.57am, he had delivered to his mid-shin, and at 6.02am, he had advanced to his nipple line and was noted to be pink, kicking and well perfused. However, a communication breakdown between ambulance crews on the ground and the control centre meant Stephanie was kept at home until 6.28am.

By the time she arrived at the hospital at 6.36am, Arthur was white, floppy and his umbilical cord was no longer pulsating with blood flow, meaning he was effectively starved of oxygen.

Dad Matt said: "It was the most traumatic thing we have ever experienced. You could hear the panic and confusion in everyone’s voices – one minute they were told to go to hospital, the next minute to stay. When the critical care paramedic arrived, he was surprised we were still at home because it was such a medical emergency.

"Since Arthur’s death, we both have doubts in the system, whereas we didn’t have those previously. We’re more hesitant when asking for help because we don’t know if we can trust professionals. We try and come up with the answers ourselves before seeking help at the last minute."

At the inquest, Assistant Coroner Dr Karen Henderson said: "I don’t underestimate the difficulty of moving [Stephanie] but that is what should have happened. I am satisfied that there was a missed opportunity to transfer her to hospital and that attempting delivery at home was not sound practice."

She went on to conclude that "Arthur died following an undiagnosed footling breech where a delay in transfer to hospital materially contributed to him suffering severe hypoxic ischemic encephalopathy."

As a result of Arthur’s death, all planned homebirths in Sussex are being offered a presentation scan at 38 weeks. At the time of Arthur’s inquest, this had been offered to 75 families, 65 of which had taken it up, identifying two babies who were unknown breech.

South East Coast Ambulance NHS Foundation Trust has also started liaising with NHS trusts throughout the South East to install red emergency phones in the labour wards of hospitals so crews transferring acute obstetric emergencies to hospital have a direct line to midwives and obstetricians, rather than A&E.

Furthermore, the Association of Ambulance Chief Executives (AACE) has changed its guidance for ambulance services and paramedics around footling breeches to provide clarification that the mother should be rapidly transported to hospital.

Stephanie, who gave birth to her second child, Primrose, eight months ago, said: "Any changes are in the right direction and really positive. I broke down at the inquest when I found out two babies had been identified as breech as a result of the scan because Arthur could have potentially saved those children."

Matt, a veterinary practice manager, added: "The only problem is that there is no guarantee these initiatives will be rolled out nationally. As far as we’re aware, they are only happening in Sussex, but these learnings should be standardised and enforced across the country to stop another parent having to sacrifice their little one in order for changes to occur."

A communication breakdown between ambulance crews on the ground and the control centre meant mum Stephanie was delayed in getting to the hospital (Image: william87/Getty Images)

As a legacy to their son, Stephanie and Matt purchased a four-acre piece of land in East Sussex, named Arthur’s Patch, where they have planted 250 native woodland trees; created a vegetable patch, a pond named after their daughter, wildflower area and a children’s play area; and installed a cabin with tea and coffee-making facilities.

Currently, they open the space up to family and friends on Saturday mornings, but eventually, they hope to create a community space where grieving parents and people suffering other losses can visit in times of need.

Stephanie said: "The vision is to create somewhere that people and nature can thrive together. Going through this, we had Arthur’s Patch to plough our grief into and we genuinely don’t know what we’d have done without that. We had somewhere to escape, plant and watch things grow. It has helped us so much and made us feel better."

Stephanie and Matt contacted law firm Mayo Wynne Baxter in October 2021 following guidance from the coroner’s office. The firm are supporting the family as part of a medical negligence claim.

Stephanie said: "We felt out of our depth. We were grieving, distraught, and we didn’t think we’d be able to handle the inquest by ourselves. We spoke to the coroner’s assistant who said we should explore being represented legally.

"If anything, we want to ensure this doesn’t happen to another family. I’ve since found out that I had all the tell-tale signs of a footling breech – such as feeling kicks in my lower stomach and a hard swelling below my ribs – but I didn’t know what they were. If I’d have read the symptoms, I’d have thought to get help and have another scan.

"We really are happy with the changes that have been made by the ambulance trust since Arthur’s death but these need to be rolled out nationally. Any compensation we are rewarded as a result of our claim will, of course, go straight into further developing Arthur’s Patch and help us in creating a space for those who need nature to heal during tough times."

Gail Waller, medical negligence partner at Mayo Wynne Baxter, said: "This really is a heartbreaking and traumatic case. There was a window of opportunity, as highlighted at the inquest, when paramedics first arrived on the scene. Stephanie should have been taken to the hospital when Arthur was still pink and kicking.

"However, the delay in this happening effectively starved Arthur of oxygen and contributed to his death. It is positive that there have been clear learnings from Stephanie and Matt’s tragic experience. Both the ambulance trust and the hospital trust have made changes as a result, which will undoubtedly save lives. However, these initiatives must be rolled out nationally to prevent other babies dying."

A spokesperson for South East Coast Ambulance Service NHS Foundation Trust said: "We would like to take this opportunity to offer our sincere condolences to Mr and Mrs Trott and we welcome any changes to national breech birth guidance aimed at improving maternity care."