‘Avoidable’ baby death due to poor pre-birth monitoring

Theo Disney-Wood was born at the Royal Derby Hospital on June 17, 2022, but died only hours later due to failings by the maternity team.

His mother, Rosie, arrived at the hospital just after midnight after contractions began. She had bleeding and Theo’s heart rate monitoring flagged concerns that he may have an infection.

The inquest into Theo’s death found that six members of maternity staff had recorded the readings, but no action was taken.

Theo should have been delivered by 5.30am, but the decision to have an assisted delivery was not made until three hours later. He was actually delivered around 10.35am, and sadly was pronounced dead just before 2pm.

The coroner ruled that Theo would not have died “but for the omissions in pre-birth monitoring”, including effective monitoring of his heart rate and accurate measurement and management of Rosie's blood loss.

The case again highlights the significant problems that exist in NHS maternity services, which is currently subject to a national investigation. The rapid review, led by Health Secretary Wes Streeting, was announced in response to the ongoing crisis in the care delivered to mothers and babies in maternity units across the country.

Law firm Slater and Gordon acts for growing numbers of families who have been impacted by poor standards of care and failings by NHS maternity services.

“Time and time again we see the tragic and utterly devastating consequences of mothers and babies not being given the care they need – and Theo’s avoidable death is yet another example of why change and improvement is so urgent,” says Jodie Cook, senior associate at Slater and Gordon.

“Maternity services are at a real crisis point nationally, and the Government-led investigation must result in decisive action to protect mothers and babies during their most vulnerable times and ensure they are no longer routinely subject to unacceptable standards of care.”