A coroner has ruled that staff failures contributed to the death of a baby who died from a brain injury in March 2023, when he was just five days old. The inquest, which examined the circumstances surrounding the incident, highlighted significant failures in the antenatal and delivery care provided by the Sherwood Forest Hospitals NHS Trust.

Arlo River Phoenix Lambert tragically died on 9 March 2024 at Kingsmill Hospital, Nottinghamshire, following a delayed labour and delivery. The coroner has identified multiple missed opportunities where timely and effective intervention could have altered the outcome.

Baby Arlo’s mother, Miss Lambert, was induced on the evening of 2 March 2023, and was subsequently left for 17 hours before any attempts were made to progress delivery. Despite Miss Lambert raising concerns about the position of the baby and the lack of progress in labour, staff members failed to implement an appropriate care plan.

Countless opportunities to monitor Miss Lambert and baby Arlo and make the decision for an emergency caesarean were missed. An autopsy report also showed evidence of Arlo’s brain suffering a hypoxic-ischaemic injury, where brain cells die due to an extended period of time without sufficient oxygen supply.

Overall, the coroner found there to be ‘systemic failings’ regarding the poor monitoring of the mother and baby during labour, an inadequate response to signs of distress, and delays in escalating significant clinical developments, concluding that Arlo’s death was contributed to by neglect.

The coroner’s findings were particularly critical of the Trust’s management practices and protocols, emphasising the need for better training, improved communication among medical staff, and stricter adherence to clinical guidelines to prevent such incidents in the future.

A Prevention of Future Death Reports was issued, recommending Sherwood Forest Hospitals NHS Trust to take immediate action to rectify the identified shortcomings. This report is a formal measure aimed at ensuring that the Trust implements necessary changes to its practices and policies to enhance patient safety and care standards.

Mass Ndow-Njie represented the family during this 4-day inquest and was instructed by Chantae Clarke of Tees Law. Mass commented:

“As a result of neglectful care, Miss Lambert never got the chance to see Baby Arlo grow into a boy and then, a man. Baby Arlo deserved to live. My hope is that this finding will lead to an improvement in the standard of care given to mothers and newborns by the Trust, ensuring that no family has to suffer in the way that Baby Arlo’s family have.”

This case is another in the troubling trend of inadequate maternity care in the UK. It follows closely on the heels of last month’s Birth Trauma Inquiry report, which revealed that substandard maternity and antenatal care is “all too frequently tolerated as normal.”


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