Maternity crisis: Coroner makes London-wide recommendations for the safe running of Midwife-Led Units following the death of baby Finn Kennedy

Finn Kennedy was born at the Oasis Birth Centre, in the Princess Royal University Hospital on 23 June 2021. He sadly died on 1 July 2021 at eight days old. An inquest into his death has found that failings in the care at the birth centre contributed to his death. The coroner concluded that a failure to properly monitor Finn’s heart rate during the second stage of labour, as well as a lack of clear leadership within the birthing centre, contributed to his tragic death.

Finn is the first child of Ruth and Martin Kennedy. Despite suffering from long covid and taking amitriptyline for severe headaches, Ruth was deemed low risk and placed on a midwife-led care pathway. She opted to give birth in the hospital’s midwife-led birthing centre, a decision which was not reviewed by an obstetrician at any point.

Upon arrival at the Princess Royal University Hospital, Ruth and Martin were forced to wait over an hour in a corridor before being triaged and assessed. Ruth waited, without support or review, to be seen whilst suffering from severe and frequent contractions before being sent to the birth centre to deliver Finn. Once Ruth reached the second stage of labour and felt the urge to push, the midwives doubted that she had reached full dilation, telling her not to push and had to be persuaded to perform a vaginal examination. The second stage of labour continued for over two hours, with Finn’s head visible for a prolonged period of time. Despite Ruth and Martin’s concerns about Finn’s wellbeing, there was no sense of urgency, no plan to expedite Finn’s birth and no obstetric support was requested.

It was agreed at the inquest that a student midwife absent of her supervisor and in direct contravention of the birth plan delivered Finn and undertook poorly carried out observations. Student midwives should be supernumerary (at work, but you do not have responsibility for patients), and whilst they can work under supervision, she should not have been having to care for Ruth alone. This led to two other midwives being present but paying little to no part in Ruth’s care and allowing incorrect observations to be taken at inappropriate intervals, if ever. This poor overall management led to missed opportunities to expedite Finn’s delivery, where he would have survived with no injury.

Finn was born in a poor condition. He was pale, floppy and unable to breathe on his own. He was transferred to Kings College Hospital Neonatal Intensive Care Unit for treatment, but treatment failed to improve his cerebral function and his parents were forced to make the heartbreaking decision to switch off his life support. Over the months and years that followed Finn’s death, his family have been subjected to poor treatment by Kings College Hospital NHS Trust, who have continually disputed their version of events and only recently acknowledged the extent of their failings. Also, the Health and Safety Investigations Branch (now under MNSI) who, in the end, refused to engage directly with the family and failed to use the errors in Finn’s care in order to form part of their education and findings.

In respect of the failures and concerns the family had towards HSIB, they were part of a national piece by Channel 4 explaining their concerns regarding HSIB, as it was, which remains largely unanswered.

Staff giving evidence at the inquest painted a picture of a chaotic environment. No permanent members of staff were working at the birth centre on the night of Finn’s birth, which was staffed by community and bank midwives. Despite having two qualified midwives in the room, no one knew who was in charge, and a student delivered Finn in contradiction to Ruth’s birth plan, which stated a preference for no students. Changes in policy since Finn’s death mean that the birth centre now closes where there are no permanent staff members available to attend. A change that came about too late for Finn and his family.

It is important to note that whilst staffing was an issue in Ruth’s care, there were enough staff present that could and should have provided safe care to Ruth and Finn would have been born and survived uninjured.

The midwives present also failed to monitor Finn’s heart rate in line with national guidelines, which require readings to be taken every 5 minutes during the second stage of labour. Finn’s observations fell well below this, and as a result, staff failed to appreciate that Finn was in serious foetal distress. Had this been evident, his birth could have been brought forward, either by caesarean section or other obstetric interventions, and he would survived.

The failures in Finn’s case were of such grave concern that the coroner opted to write a letter of recommendation to the London Maternity and Neonatal System, which has oversight of midwife-led units across London. The letter will require a formal response and will recommend that all midwife-led units have safe and robust policies around:

• closure of birth centres where it is not possible to provide safe care
• availability of staff and ensuring permanent members of staff are on duty
• clear leadership and handovers within a unit.

Finn’s death certificate states that he died as a result of Hypoxic Ischemic Encephalopathy, which is caused when the brain is deprived of oxygen for a prolonged period. There is no doubt that this injury occurred during his birth, or that it would have been avoided had he been born earlier. This was reflected in the coroner’s decision to add “delay in delivery during the second stage of labour” to Finn’s official cause of death.

Bethany Kyle, Solicitor in the Medical Negligence team at Ashtons Legal, who represents the family comments:

“Finn’s family have fought tirelessly to uncover the truth of what happened to their son. Their story has been denied and diminished on so many occasions. The inquest has made clear that Finn’s death was a result of easily avoidable errors, something Ruth and Martin were sadly already aware of.

“Today’s launch of the government’s Birth Trauma Enquiry is a reminder that the poor maternity care Ruth and Martin experienced is a widespread and national issue. Ruth’s concerns and instincts were wrongly dismissed by the midwives present, an issue which is central to the enquiry. We hope that the enquiry represents a step towards improving standards and avoiding the needless loss of babies like Finn.

“Whilst problems around staffing are a real concern, the crisis facing maternity services runs much deeper than this. Poor management and practices have led to systemic issues which prevent the most basic levels of care being provided. Finn died as a result of not receiving these basic levels of care, despite there being two fully qualified midwives and a student present”.

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