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Health board’s ‘silence’ over fatal accident inquiry

Montrose Infirmary.
Montrose Infirmary.

A sheriff has expressed his concerns over a health board’s “total silence” during investigations into a baby’s death at an Angus maternity unit.

Nevaeh Stewart died three-and-a-half hours after she was born at Montrose Royal Infirmary’s community midwifery unit on September 30 2012, despite the efforts of specialists who arrived to save her.

An inquiry into Nevaeh’s death is being held at Forfar Sheriff Court, where her father Gary Stewart earlier described the unit as an “emergency response blackspot”.

While the water birth and neonatal care of Nevaeh and her mother Kimberly was placed with NHS Tayside, the inquiry heard the obstetric care before labour was co-ordinated with Mrs Stewart’s “home” health board, NHS Grampian.

Sheriff Pino Di Emidio told the inquiry he was considering writing to the board over Grampian’s non-participation since the initial Significant Clinical Event Analysis.

The inquiry had been told Mrs Stewart had told midwives she had found a “clot” on July 16 that year, which was relayed to experts at Aberdeen Royal Infirmary.

Mrs Stewart, from Auchenblae, was considered a “low risk” pregnancy and it was decided during the phone call that she did not need to be admitted to a ward at 28 weeks.

Dr Julia Sanders, a midwifery expert from Cardiff, said the decision to admit Mrs Stewart would have rested on the consultant taking the call.

“It is possible there may have been a conversation where a review is not required, but not if clots had been mentioned,” she said.

The inquiry heard there was no record of the telephone conversation.

The sheriff had previously expressed concern that electrocardiograph results had been sent by a Montrose midwife to ARI the day before she went into labour, but no response had been made.

NHS Grampian is not represented at the FAI.

Sheriff Di Emidio said: “This is another case in which the absence of information from Grampian is a difficulty here.

“There has been no participation in the SCEA or in proceedings

“I am considering having the sheriff clerk write to NHS Grampian to air my concerns.

“There’s been absolute silence here.”

The inquiry previously heard the cause of Nevaeh’s death had been attributed to hypoxia or lack of oxygen in the soft tissues, but neither the SCEA or clinical evidence could explain why.

The inquiry continues.

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