Midwives took ‘too long’ to bleep doctors after birth of Ida Lock, experts say

Two obstetric experts testified at an inquest that midwives attending the birth of a baby who later died were overly focused on monitoring the fetal heart rate and should have urgently summoned a doctor sooner. Sarah Robinson arrived at the Royal Lancaster Infirmary’s delivery suite in labor, requesting a water birth. Despite midwife Lisa McGrow noting the baby’s heart rate had dropped below normal, Sarah was permitted to enter the birthing pool.

Amanda Sailor, a senior midwife, joined to assist, and both midwives repeatedly attempted to check the baby’s heart rate. It wasn’t until 15 minutes after Sarah entered the pool, following unsuccessful efforts to monitor the heart rate, that they called for a doctor.

At 10:42 am, Sarah’s daughter Ida was delivered, not breathing and in critical condition, with the umbilical cord around her neck. Midwife Amanda Sailor and delivery suite coordinator Celia Sykes, the trust’s current bereavement midwife, began initial resuscitation attempts.

After three and a half minutes of ineffective efforts, Dr. Matthew Phillips arrived and took over. Until then, Ida had received no oxygen. She was transferred to Royal Preston Hospital but passed away seven days later from a severe brain injury caused by oxygen deprivation. The inquest into Ida’s death, initiated only after her parents directly contacted the coroner, began last week at County Hall in Preston.

Today, the inquest heard from two prominent obstetricians reviewing the case. Dr. Mark Waterstone of Dartford and Gravesham NHS Trust stated that fetal heart rate readings after 10:10 am, when Sarah entered the pool, were unreliable, and the midwives were “too focused on finding the heart rate.” He remarked, “There’s a total lack of awareness. No one knows what’s happening. This is a recurring issue in problematic cases I see—why isn’t anyone acting? They’re wasting time. Move the patient to theater and figure it out there. In obstetrics, things can deteriorate rapidly, and you must respond swiftly.”

Dr. Nicholas Myerson of Bradford Royal Infirmary concurred, noting an apparent “urge to see normality where the conditions for it weren’t present.” He argued that Sarah should not have been allowed into the pool, especially while feeling a strong urge to push, given the warning signs that her labor was no longer low-risk. “She simply shouldn’t have been in that pool,” he emphasized.

Both experts agreed the obstetrics team should have been involved earlier. Dr. Waterstone added that if Sarah was fully dilated at 10:10 am, as he believes, “it was neither safe nor appropriate” for her to enter the pool at that point. The 17-day inquest continues.

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