Coroner calls for extra training for paramedics after death of newborn baby from Oakham

Terri Tissier and Gavin Bailey at home in Oakham.'Photo: MSMP110713-004ow
Terri Tissier and Gavin Bailey at home in Oakham.'Photo: MSMP110713-004ow
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A coroner has called for changes in national guidelines after he heard the life of a newborn baby could have been saved if paramedics had been allowed to help deliver her.

Assistant deputy coroner Robert Chapman said no-one was to blame for the death of Lucy Bailey, who was born on September 16, 2010, and died 38 hours later in hospital.

But Mr Chapman is now writing to the expert committee, which issues national guidelines for paramedics to follow, urging it to allow paramedics to physically intervene in the delivery of babies.

An inquest into Lucy’s death in Loughborough on Wednesday heard that the baby’s mother, Terri Tissier, went into labour at 4.30am on September 16 at her flat in West Road, Oakham,

Terri called her mother Lyn Richardson, who lives in Stamford, who was due to drive her to hospital and be her birthing partner.

When Lyn arrived, Terri believed it was too late to go to hospital because her contractions were strong. Her partner Gavin Bailey called 999 for an ambulance.

The inquest heard that when East Midlands Ambulance Service paramedic Adam Martin and his assistant Tony Barber arrived, they tried moving Terri into different birthing positions to help move the delivery along. As the baby’s head began to crown they called for the midwife.

When the midwife, Victoria Buxton, arrived she was told the baby’s head had been visible for six minutes but the baby’s body was not coming out.

Mrs Buxton then put Terri into a different position and managed to release Lucy’s umbilical cord and her shoulders, which had become stuck.

Lucy was born at 8.14am and was taken to Leicester Royal Infirmary because she was pale in colour, not breathing and had no heartbeat.

In the ambulance, paramedics managed to get Lucy’s heart beating and at hospital the baby was put in an incubator with a ventilator.

Despite the efforts of the paramedics, midwife and staff at the hospital’s neo-natal unit, Lucy was unable to breathe unassisted and a brain scan found there was no sign of activity.

Terri made the decision to turn-off Lucy’s ventilator 38 hours later and Lucy died at 10.14pm on September 17.

Mr Martin told the inquest that according to the UK Ambulance Services Clinical Practice Guidelines, which is written by the Joint Royal Colleges Ambulance Liason Committee, paramedics are allowed to assist the mother in breathing and help her into different birthing positions, but are not trained to assist in pulling out the baby or physically intervening.

Mr Martin said: “There is nothing I could have done differently because of the limitation in training. All we could do is follow our guidelines and reposition her. We were stuck with our options.”

Mr Chapman recorded a narrative verdict, which said it was likely Lucy had died from “oxygen starvation to the brain”.

He said he would be writing to the Joint Royal Colleges Ambulance Liasion Committee, urging it to review the way in which paramedics can handle births to stop potential cases like this happening again.

He said: “The paramedic, Mr Martin, was very limited in what he could do.

“There are limits in what is outlined in their training and it’s all hands off. They were not allowed to assist in pulling baby Lucy out.

“Clearly had they had that maternity training it may be that she would have been born and be here today.

“I feel it’s something I need to bring to attention.

“I’m going send a letter to those who write the guidelines to tell them what needs to be discussed and that further maternity training is needed, because in this case it may have been possible to save Lucy’s life if the paramedics could have helped release her.”

Terri and Gavin have since had another baby. Their son Ethan was born on March 21 last year. They also have a six-year-old son Luke, who attends English Martyrs Primary School in Oakham.

Speaking after the inquest, Terri, now 24, said: “It’s been a difficult three years but I’m very pleased with the outcome and it feels like we’ve got some closure.

“I’m glad the coroner has taken it seriously and wants to do something about it.

“Lucy will never be forgotten and I’ll always think of her as my little girl.”

Terri has since set up Lucy’s Hope 4 Others to raise money for the neo-natal unit and has so far raised more than £1,000.

She praised the unit as being “fantastic” and said its staff were “amazing people”.