A MUM has said she will continue to work with Warrington Hospital to make 'positive changes' after her daughter died less than 30 minutes after being born.

An inquest into the death heard a series of errors preceded the birth and following nine other stillbirths at Warrington Hospital an investigation was launched into what was going wrong.

Caroline Tully, from Penketh, told the hearing on Thursday at Warrington Coroner's Court she went to the maternity unit in the early hours of March 7 last year after her contractions were two minutes apart.

But she was told by midwife Sophie Kingsbury she should go home and ‘relax’.

She added: "Miss Tully came across as calm and appeared to be coping well with the pain..we make these judgements on a daily basis."

Coroner Nicholas Rheinberg said midwife Kingsbury's perception of the situation was wrong after the inquest heard Miss Tully was struggling to walk back to her car with her partner Tom as the pain got worse.

They drove the short distance back to Penketh before Miss Tully said it felt like her pelvis had ‘shattered’ and she could see blood on the carpet.

She added: "Tom got me back in the car but I couldn't stop screaming.

"(I was in so much pain) I bit into the metal bar of the car's head rest and cracked my back tooth."

The pair were rushed into the delivery suite but no sound came from Clara when she was born and the team could not resuscitate her.

Miss Tully added: "I thought this can't be happening and to this day I'm still in shock.

"I was willing her to cry but as the minutes ticked by on the clock I knew it had been too long."

Days later, the department went against NICE guidelines and introduced continuous monitoring for all pregnant mums going into labour.

Midwife Melanie Hudson said this was not a 'direct response' to Clara's death but the incident did 'form part of the decision'.

A series of changes have now been brought in following errors including staff's failure to pass on or follow up information regarding a family history of pre-eclampsia leading to Miss Tully being incorrectly classed as 'low risk' throughout her pregnancy.

Mr Rheinberg said there were ‘elements of chaos’ during Miss Tully’s pregnancy after the inquest heard she received two phone calls congratulating her on her birth when she was only five months pregnant.

He also questioned why only twice she saw the same midwife, queried problems over midwives accessing IT systems and was critical of a trainee GP and midwives 'tendency to explain away' a high blood pressure reading from Miss Tully rather than investigate further.

Sickness and absence was blamed for Miss Tully not having the same midwife throughout her pregnancy and the court heard a buddy system had now been brought in so pregnant mums would see one of two midwives.

GROW charts had also been introduced after a midwife miscalculated Miss Tully was 32 weeks rather than 34 weeks pregnant.

Clara had previously been classed as stillborn but Mr Rheinberg recorded she had died of natural causes.

CORONER Nicholas Rheinberg said he was satisfied enough changes had been made to avoid ordering an investigation but expressed frustration inquests cannot be held into stillbirths during labour. 

Mr Rheinberg added: “It’s very unfortunate coroners are restrained in investigating deaths where there has been shown to be signs of life during delivery. The greater medical distress the more likely it is the foetus will be born dead and it seems to be perverse these cases shouldn’t be fully investigated.”

The couple said they welcomed the findings.

They added: “We believe our daughter’s death highlights the need for inquests into cases of stillbirth during labour. 
“We welcome the many improvements already made at Warrington Hospital following Clara’s death and will continue to work with the hospital and charities to help make positive change.” 

Karen Dawber, director of nursing, said their ‘heartfelt sympathy goes out to the family’ and they have fully implemented recommendations and made significant improvements to the antenatal risk assessment process. 
She added: “We continually look at ways to ensure we deliver high quality care and make improvements to the services we provide.”