Airedale Hospital: Baby's death 'contributed to by neglect'

An inquest at Bradford Coroners' Court last month heard how Alfie Hinton died at 23 minutes old at Airedale Hospital as a consequence of complete umbilical cord occlusion leading to a hypoxic ischemic brain injury.

Prevention of Future Deaths Report

Assistant coroner Charlotte Keighley sent a Prevention of Future Deaths Report to Airedale NHS Foundation Trust on Monday, December 2.

The report said: "On 21 May 2019, I commenced an investigation into the death of Alfie Hinton, aged 23 minutes. 

"The investigation concluded at the end of the inquest on November 13, 2024. 

"The conclusion of the inquest was that Baby Alfie Hinton died as a consequence of hypoxic ischemic brain injury sustained during the intrapartum period arising from delays in the management of his medical care.  

"His death was contributed to by neglect."

The trust told the Telegraph & Argus that it is "very sorry that our care fell short of our usual high standards".

It said it is "committed to ensuring that concerns from the coroner will be acted upon"

The trust also added that a "number of procedural changes" have already been made as it learns from this "very distressing incident”.

The trust must respond to the report within the next 56 days by January 27, 2025.

Circumstances

In the days leading up to his death and whilst in utero, Alfie experienced a period of chronic hypoxia arising from placental insufficiency which made him more vulnerable to any further hypoxic events, the report said. 

On May 8, 2019, Alfie’s mum was admitted to hospital through the Maternity Assessment Centre for induction of labour as a consequence of extremely high levels of bile acids, which were recorded at 149 - anything over 100 increases the risk of stillbirth tenfold.

Induction of labour was requested ‘as soon as possible’ - the expectation being that this would commence, at the latest, the following morning, the Prevention of Future Deaths report added. 

However, the induction did not start until 10.50pm on May 9 following a "significant delay arising from the unavailability of beds on the Labour Ward".

Once it began, the plan was for six-hourly fetal monitoring with additional monitoring at the point when contractions commenced.

At some point between 7am and 9.04am on May 10, Alfie experienced an acute hypoxic event from which he recovered.

Assistant coroner Charlotte Keighley said in the report that the effects of this would have been recognised earlier had monitoring taken place on time or alternatively at the point when contractions commenced.

At the time of the contractions, staff on the ward were engaged with other patients, consequently, there was no one to inform.

The scheduled six-hourly monitoring was delayed by 39 minutes with bradycardia being identified soon after the commencement of the trace, the report said. 

The bradycardia was not acted upon immediately and therefore preparations for birth were delayed, it added. 

There were further delays once preparations commenced and, at some point during the 12 minutes prior to Alfie’s delivery at 2.41pm, a complete cord occlusion occurred from which Alfie was unable to recover. 

Upon delivery his heart was slow and, despite resuscitation attempts, Alfie did not survive. His death was confirmed at 3.04pm.

Coroner's concerns

In the inquest, assistant coroner Keighley had concerns about how "information was gathered and shared within the maternity unit and in particular how risk is recorded and communicated between all of those involved in providing intrapartum care".

She also had concerns around "communication, ongoing risk assessment and an absence of local policy in respect of the approach to be taken in such time critical situations".

Full Airedale NHS Foundation Trust statement

Lianne Robinson, interim chief nurse at Airedale NHS Foundation Trust, said: “Our deepest sympathies go to Alfie’s family and we are very sorry that our care fell short of our usual high standards.

“We are committed to ensuring that concerns from the Coroner will be acted upon.

"Following Alfie’s death in 2019, we have made a number of procedural changes, and will continue to review our practices to ensure we learn from this very distressing incident.”