6 days ago
Sheriff recommends staff review at Glasgow hospital where baby died
Sheriff Barry Divers presided over the fatal accident inquiry (FAI) of Freya Murphy.
Little Freya died from a brain injury at Glasgow's Queen Elizabeth University Hospital on Saturday, July 28, 2018.
Freya had suffered from the 'Group B Streptococcus' viral infection, which infects 45,000 mothers.
The probe into the death took place at Glasgow Sheriff Court last year.
The hearing was told that Freya's mother, Karen Murphy, 32, had no initial problems with her pregnancy, which started in October 2017.
Reduced foetal movements had been reported on July 11, 2018, for the first time.
Teacher Karen, of Cambuslang, Lanarkshire, went into labour on the night of July 20, 2018 and was asked to push at 6.30am the next morning.
Karen was told 30 minutes later that she could rest from pushing, but opted to continue as it was more comfortable with her contractions.
Doctor Amy Sinclair left Karen's care after 9am to perform a delivery to another patient and later returned.
Freya was then delivered at 9.31am and taken for emergency neonatal assistance with consultants.
The newborn required chest compressions, and her heart rate increased to 100 beats per minute.
She was put into the ICU, and she was suspected to have suffered multiple organ failure.
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Freya remained in intensive care from July 21 until July 28, where she was found to have suffered a "significant brain injury" and was completely dependent on a ventilator.
It was deemed that intensive care was not in Freya's "best interests" and she was then put on palliative care.
She was pronounced dead at 9.50pm aged seven days and 12 hours.
A post-mortem carried out gave Freya's cause of death as 'global ischemic brain injury associated with chorioamnionitis'.
Doctor Michael Munro, 58, was asked by fiscal Amanda Allan if an earlier delivery would have made a difference to Freya's life.
He replied: "Early delivery would have to have made a difference, but as to how much difference, that's the problem I can't say."
The hearing was told that Freya and another patient both needed urgent delivery at the same time, which created a "horrific perfect storm", according to Doctor Felicity Watson.
Dr Watson added that an appropriate number of doctors would have been available to both babies had they been delivered on a weekday.
A reduced number of staff were on the ward at the weekend compared to weekdays.
The hearing was told that "no satisfactory explanation" was given for the difference.
Crown submitted that staffing levels on the maternity ward were a "factor in Freya's death."
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Sheriff Divers told the probe: "Having two women who might need to be admitted to theatre as emergencies at the same at the weekend created a problem.
"That problem was that there was insufficient staff for them to open a second theatre to allow both to be dealt with simultaneously."
The sheriff, however, did not find that this resulted in a realistic chance of Freya surviving.
Sheriff Divers did recommend that the Greater Glasgow Health Board (GGHB) "review its staffing levels to meet the needs of patients."
This includes its labour wards, post-natal wards, maternity assessment units and other hospital maternity-related areas.
Sheriff Divers also recommended that the GGHB request that the United Kingdom National Screening Committee give urgent consideration to a review of whether pregnant women should routinely be offered screening for Group B Streptococcus.
Freya's mum Karen and dad Martin Murphy gave a statement before the start of the probe.
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They said: 'I want to take the chance to share something about our beloved daughter. She was our first baby.
'We were surprised by her responsiveness to her daddy's voice and her change in movements when different music played.
'She was an active baby until the last minutes before she was born. Our lives were completely shattered when Freya arrived seriously ill.
'Over the years, we continue to be shocked that we had no warning that she was struggling, and there was no urgency in our care.
'We ask that you remember that Freya wasn't just a newborn baby that died - she would be six years old and in primary two.
'We have missed lifetime memories of our precious daughter, and the void left by her death is unimaginable.
'We have suffered indescribable pain and continue to do so. Our mental and physical health continues to deteriorate dramatically, and every day of our lives are impacted.
'Our confidence has been shattered, our ability to work, our concentration and our friendships. There have been no areas in our lives that has been untouched, and our other children suffer as their big sister is largely missed.
'We hope this investigation into our daughter's death, the health board and individuals will reflect on the huge span of our loss and will be open to changes that will improve procedures and ensure this doesn't happen to another family.'
