A coroner has written to an NHS trust and the UK Government to raise the alarm about maternity care after “gross” and “incompetent” failures by midwives to properly care for a baby during birth led to her death.
Coroner James Adeley, in a Prevention of Future Deaths Report following the inquest of baby Ida Lock, heavily criticised clinicians and leaders at University Hospitals of Morecambe Bay NHS Foundation Trust for their conduct before and after she died.
“Urgent action is required by the trust to meaningfully embed the duty of candour”
James Adeley
Dr Adeley said lessons had still not been learned from the 2015 report by Dr Bill Kirkup into maternity failings at the same organisation and accused the trust of being “defensive” in the aftermath of Ida’s death.
On 9 November 2019, Ida’s mother Sarah Robinson attended Royal Lancaster Infirmary’s labour unit, which is operated by Morecambe Bay, to give birth to her daughter.
Ms Robinson was taken into a birthing pool despite a slowing of her unborn baby’s heart rate and other signs that this was “inadvisable”, before being rushed out due to concerns about Ida’s health.
Ida was delivered pale in colour, with a low heart rate and severe hypoxic ischaemic brain damage.
A “wholly ineffectual” resuscitation attempt then took place by maternity staff, before the procedure was taken over by a paediatric registrar.
Ida was transferred to intensive care at a different hospital and died a week later, on 16 November.
Initial internal investigations by the trust did not determine that there were any issues with Ida’s care.
However, a Healthcare Safety Investigation Branch (HSIB) report, published in April 2020 and carried out as part of the Maternity and Newborn Safety Investigations (MNSI) programme, painted a completely different picture.
It found that there had been failures in care before and after Ida was born; HSIB’s findings were credited as being the trigger for the inquest into her death, which opened the following year.
The inquest, overseen by Dr Adeley, concluded on 21 March 2025, more than five years after Ida died.
It found that Ida’s cause of death was brain damage caused lack of oxygen during her delivery, which occurred due to the “gross failure of the three midwives attending her to provide basic medical care” and deliver her urgently when it was “apparent” she was in distress.
Further, the inquest ruled that Ida’s death was contributed to by the “wholly incompetent failure” by the lead midwife to provide basic neonatal resuscitation for Ida during the first three-and-a-half minutes of her life.
In evidence, the inquest heard how the trust’s internal investigation after Ida’s death concluded there were “no issues” and that “everyone has done very well”, according to local press.
Ms Robinson and Ida’s father, Ryan Lock, told Sky News that the trust put up a “huge wall” when they tried to find out what happened to their daughter. The mother said she was made to feel like it was her fault.
Following the inquest, the coroner has written to the trust, the Department of Health and Social Care, NHS Lancashire and South Cumbria Integrated Care Board and NHS England to outline what went wrong in an attempt to stop another case like Ida’s happening again.
This document, known as a Prevention of Future Deaths Report, said there were “multiple missed opportunities for enhanced care and obstetric input” during Ms Robinson’s labour.
These included a failure to act on signs that made it “inadvisable” for Ms Robinson to enter the birthing pool, and a failure to act on a “significant slowing” of Ida’s heart rate shortly before the baby was delivered.
Further, midwives lacked “urgency” in asking Ms Robinson to exit the pool, to obtain crucial heart rate monitoring equipment and to gain obstetric help at an “appropriate” time.
Midwives, the document stated, were “task focused” on obtaining a heart rate for the baby and took reassurance from “unreliable heart rate readings”.
These caused an “avoidable delay” in getting help for Ms Robinson and her baby.
The prevention report aired significant concerns about the quality of the investigation after Ida’s death, as well as about the culture within the organisation.
The coroner drew comparisons between this case and those mentioned in the 2015 Kirkup Report, which concluded that one mother and 11 babies could have been prevented from dying if they had been given different clinical care.
He wrote: “I am concerned that there is not a culture of candour within [the trust], and the impact that this has on safety, learning and implementing required changes to prevent deaths.
“Urgent action is required by the trust to meaningfully embed the duty of candour.”
One witness to the inquiry demonstrated a “deep-seated and endemic culture” within the trust to deny and to not learn from mistakes, the document continued.
“Issues and themes identified in 2015 were very much in issues in 2019 and still exist at the trust as identified by Ida’s inquest,” the coroner wrote.
The trust was accused of lacking transparency and openness in the inquest proceedings themselves, with a failure to provide relevant information and to identify the “defective” clinical governance processes at the trust.
The coroner wrote: “All investigations conducted by the trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report.
“In view of the continuing culture at the trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the trust.”
He acknowledged that there had been some improvements to date in this area, but said he “remained concerned” that the trust was not “fully engaged” with the duty of candour.
Meanwhile, the coroner highlighted how there had been no investigation into the current head of midwifery at the trust in respect of her disputing the HSIB’s findings of fault at the trust.
Further, he said it concerned him that the trust lacked robust systems to make sure midwives who did not complete mandatory training were subject to “immediate action” to remedy this.
This was, in part, raised due to the revelation during the inquest in March that a band 5 midwife who was supporting Ms Robinson during labour had not undertaken mandatory training.
“We accept that we failed Ida and her family”
Tabetha Darmon
The coroner also said there was not any remedial training for the midwives involved in Ida’s delivery, and that this was also something that needed addressing.
Dr Adeley further identified some concerns he had on a national level.
He pointed to the fact that the MNSI programme, now hosted by the Care Quality Commission, is funded for the next two years but lacks certainty after this.
The coroner described these independent investigations as an essential safeguard and said significant harm or deaths like Ida’s could go unrecorded, and lessons not learned, if this is not addressed.
Tabetha Darmon, chief nursing officer at Morecambe Bay, said the coroner’s conclusions were being taken seriously, and that the organisation had already made some improvements identified during proceedings.
“Losing a child is tragic and our heartfelt condolences go out to Ida’s parents, family and loved ones. We are truly sorry for the distress we have caused,” said Ms Darmon.
“We accept that we failed Ida and her family and if we had done some things differently and sooner, Ida would still be here today.
“We also acknowledge the additional upset caused to Ida’s parents and family as a result of the way investigations into Ida’s death have been conducted since 2019. For that, we are truly sorry.”
Ms Darmon continued: “We are carefully reviewing the learning identified to ensure that we do everything we can to prevent this from happening to another family.
“There is still a lot of work to be done, and our teams remain committed to continuously improving maternity services for women, pregnant people and families across Morecambe Bay.
“We know none of this can take away the pain Ida’s family and loved ones will be feeling. We know we need to do better, and we will be leaving no stone unturned to learn from the ways we failed and improve the care we provide in the future.”
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