A TWO-DAY-OLD “deeply loved daughter, sister and granddaughter” died of an umbilical cord accident during labour causing lack of oxygen and blood flow to the brain.
An inquest concluded on Monday, November 9, that two-day-old Blossom Louise Benstead-Wright died from hypoxic-ischaemic encephalopathy after an umbilical cord accident during labour.
Dorset area coroner Brendan Allan heard that Blossom was born at St Mary's Maternity Unit on August 12, 2024, before being transferred to Southampton for specialist treatment. She later returned for palliative care with her family and died on August 14.
Samantha Benstead-Wright warned that she was not suitable to give birth in the low-risk Haven Suite, but staff transferred her there from the antenatal ward.
Blossom’s heart rate slowed on the CTG, so staff carried out an emergency caesarean section.
Cord-blood gas results showed Blossom was seriously unwell, and she was transferred to a neonatal intensive care unit in Southampton.
Mr Allan heard that Mrs Benstead-Wright’s pregnancy was classed as high-risk because of factors including her high BMI and low PAPP-A levels.
She had been pregnant 14 times, suffered multiple miscarriages and an ectopic pregnancy, and had two sons, born in 2011 and 2022.
During her previous two labours, she had continuous CTG monitoring through a foetal scalp electrode.
The risks were recorded on the BadgerNet maternity system and available to the midwives and doctors treating her on the night of August 11.
But the coroner found that staff failed to properly review her pregnancy summary and risk factors before transferring her to the Haven Birthing Suite.
Midwives decided she was ready to move, but she questioned the decision, asking: "Are you sure I can go? I haven't got any thinner or any younger." Mr Allan said she was right to raise the concern because of her known risk factors.
The coroner found that continuous CTG monitoring should have been used because experts said it could have detected problems with Blossom’s heart rate sooner and allowed earlier treatment.
Despite this, he concluded there had been no gross failure in medical care.
He said staff acted quickly and appropriately once they recognised the emergency, and that Blossom received appropriate care in the Haven Birthing Suite.
Mrs Benstead-Wright said: “The past two years and three months have been the most difficult times of our lives.
“On 11 August 2024, we arrived at hospital full of excitement as induction of labour began and we prepared to meet our longed-for baby girl.
“Instead, our lives changed forever.
“Blossom was a deeply loved daughter, sister and granddaughter.
“Her loss has left an immeasurable and permanent void in our family, and not a day passes without us thinking about her.
“Throughout this inquest, our priority has been to understand what happened to ensure lessons are learned.
“We heard evidence that, despite being categorised as a high-risk patient requiring consultant-led care, decisions were made to transfer me to the Haven Suite, a low-risk, mid-wife led unit, without appropriate consideration of my recognised risk factors and without foetal monitoring.
“We now know that I did not meet the criteria for labouring on the Haven Suite.
“At the time, I repeatedly told staff that I had been advised I could not labour on the Haven Suite.
“We firmly believe that we were in the wrong place, receiving the wrong care.
“During labour, we questioned what was happening and repeatedly raised concerns, but we feel our voices were not heard.
“While nothing can ever bring Blossom back, we have seen that changes have been made since her death.
“Today does not mark the end of our grief, but we hope that Blossom’s legacy will be one of positive change.
“If improvements are made and lives are saved because of what has been learned from her death, then her short life will continue to make a difference to others.”
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