According to a report by Michael Buchanan, a social affairs correspondent for the British Broadcasting Corporation (BBC), a newborn infant died due to the failure of three midwives to provide basic medical care, a case that the coroner ruled as gross negligence. Baby Ida Locke was born at the Royal Lancaster Infirmary (RLI) on November 9, 2019, and tragically passed away a week later due to oxygen deprivation leading to severe brain damage.
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03-29, 2025Following a five-week inquest at Preston Coroner's Court, Coroner James Adley concluded that Ida's death was caused by the midwives' failure to "expedite her delivery when she was clearly in distress," and that the principal midwife's "complete incompetence in failing to provide basic neonatal resuscitation" also contributed to the tragedy. He pointed out that there were a total of eight missed opportunities to "change Ida's clinical course."
The inquest heard that Ida was transferred to the neonatal intensive care unit at the Royal Preston Hospital and died on November 16, 2019. Previous hearings also revealed that an independent Healthcare Safety Investigation Branch (HSIB) report in April 2020 identified multiple failures in Ida's care that contributed to her death. The report stated that the midwives failed to recognize an abnormally slow fetal heart rate during the early stages of labor for Ida's mother, Sarah Robinson. HSIB concluded that resuscitation efforts were ineffective after Ida was born.
However, an internal "root cause analysis" conducted by the hospital in January 2020 found no issues and instead praised the "high level of cohesion and communication" demonstrated by the labor ward staff. After reading these two "diametrically opposed" reports, Ida's parents, Ms. Robinson and Ryan Locke, filed a complaint with the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT), which operates the hospital.
While delivering his conclusion, Dr. Adley stated, "Ida was a normal child, and her death was caused by oxygen deprivation during labor due to the failure of three midwives to provide basic medical care and expedite her delivery when she was clearly in distress." He also noted that the principal midwife was "completely incompetent" in providing basic neonatal resuscitation during the first 3.5 minutes of her life, which further exacerbated the infant's brain damage.
The senior coroner also criticized the hospital's investigation into Ida's death, calling it a "damning indictment of a dysfunctional, discombobulated and callous system that failed this family at every opportunity." The Morecambe Bay University Hospitals NHS Foundation Trust was also criticized in a scathing 2015 report, which found a "lethal mix" of problems at another maternity unit at Furness General Hospital, leading to the unnecessary deaths of 11 babies and 1 mother between 2004 and 2013. The Morecambe Bay Inquiry, led by Dr. Bill Kirkup, revealed a series of failures at "every level," from the department itself to the agencies responsible for regulating and monitoring the trust.
UHMBT Chief Nursing Officer Tabitha Damon said in a statement: "The loss of a child is a tragedy, and we offer our deepest condolences to Ida's parents, family and loved ones. We are deeply sorry for the pain caused. We recognise that we let Ida and her family down, and if some actions had been taken differently and sooner, Ida would still be here today. We also recognise the additional distress caused to Ida's parents and family by the way the investigation into Ida's death was handled since 2019. We are deeply sorry for this. We take the coroner's conclusions very seriously and have made many improvements identified in the investigation. We are carefully reviewing the lessons identified to ensure we do everything possible to prevent this from happening to other families again."
