Molly Dimmock died shortly following her birth aged just 34 minutes on 25 June 2020. Emma-Louise Fenelon represented her family at an inquest into the circumstances of her death before Senior Coroner Crispin Butler, who found that Buckinghamshire Healthcare Trust and staff at Stoke Mandeville Hospital had underestimated her size and failed to identify accelerated foetal growth when her mother Charlotte attended for her 36-week ultrasound scan. As a result, Charlotte was not warned about the heightened risks of carrying a Large for Gestational Age (LGA) Baby and in particular the risk of shoulder dystocia (a birth injury during which one or both of a baby’s shoulders becomes stuck inside the mother’s pelvis during delivery).
The coroner drew attention to the absence of a national definition of LGA baby and the difficulties this caused clinicians, and consequential risks to mothers and babies, having heard evidence that some Trusts define this as babies above the 90th centile, whereas Buckinghamshire Healthcare Trust considered only babies above the 95th centile to be LGA. He noted that if Molly’s size been correctly identified then the care pathway would have been different for her, her parents and her clinicians.
The Coroner sent a Prevention of Future Deaths report to the National Institute for Clinical Excellence, the Royal College of Obstetricians and Gynaecologists, NHS England and Buckinghamshire Healthcare Trust outlining his concerns that there remains a continuing risk of future deaths to both mothers and babies as a result of the absence of a definition of LGA baby.
Emma-Louise Fenelon was instructed to act on behalf of the family by Sonia Rani, Hodge Jones Allen Solicitors.