Maternity rules rewritten after hospital failings

Neonatal Unit at The Royal Oldham Hospital

Guidelines dictating induction procedure for women in labour will undergo wholesale revision and improvement following the tragic death of Spencer Butler at the Royal Oldham Hospital.

Spencer’s mother Natasha was admitted to the maternity unit in May for induction - a process that continued for three days.

On 17 May she was transferred to the labour ward when Spencer showed signs of distress. An emergency Caesarean section was carried out but Spencer died from from damage to the central nervous system caused by an inadequate supply of oxygen — 33 minutes later.

An inquest in Heywood heard there was a gross failure in care and a catalogue of errors and missed opportunities that led to Spencer’s death.

Coroner Lisa Hashmi said Spencer may have survived if a caesarean had been carried out at an earlier stage. She found a link between errors and omissions made and the unprecedented level of activity on the maternity unit when Mrs Butler was in labour. She said that “apathy prevailed when it came to practical thinking.”

The inquest heard that medical and midwifery neglect was a major factor in Spencer’s death.

Gill Harris, chief nurse at the Pennine Acute Hospitals NHS Trust, which runs the Royal Oldham Hospital, said: “We fully accept the coroner’s findings following the sad death of baby Spencer last year. This is a terribly tragic case.

“Without question The Pennine Acute Hospitals NHS Trust let down Spencer and his parents in aspects of the care provided. For this we are truly sorry.”

She added: “We have learned significant lessons from the detailed internal investigation we carried out. Immediate action has been taken and improvements made to our systems and processes, particularly around induction of labour guidelines.”

These include a wholesale revision and improvement of the trust’s induction of labour guidelines; a focus on training and education for all necessary staff’ improvements in handover procedures and spot checks and audits to monitor compliance.