A fatal accident inquiry into the tragic death of a baby girl heard none of Scotland’s community midwifery units have “blue light” response in an emergency.
Tragic Nevaeh Stewart was born at Montrose Royal Infirmary’s community midwifery unit (CMU) in 2012 but became ill and died soon after her delivery in a birthing pool.
Her parents, Gary and Kimberley Stewart from Auchenblae in the Mearns, told a hearing at Forfar Sheriff Court that they expected “blue lights” and emergency transit to Ninewells Hospital when their baby became ill – but none came as CMUs have no such recourse.
Mrs Stewart, 31, said she was not advised of any dangers associated with pool births, and she only held little Nevaeh “very briefly” after her baby looked “quite pale” on September 30.
The couple said that they would “never” have elected to have the baby in Montrose if it was clear to them that it would take up to four hours for a neonatal transit ambulance to attend an emergency.
“I think it is important for people to know that things like this can happen and do happen,” Mrs Stewart added.
“You would expect blue lights.
“That’s what we were led to believe – 30 to 40 minutes then the baby would be transferred to hospital.”
Mrs Stewart said two of her first three children had been born at the same CMU.
“I can categorically say I would not have had my girls at Montrose if I knew I would be putting my girls and myself at risk,” she said.
Fiscal depute Nicola Ross said: “If at any stage during the pregnancy you were told that if there were any difficulties with the birth, if it would take several hours to get you transferred from Montrose midwifery unit, would you have gone there for the birth?”
Mrs Stewart said: “Never.”
After her waters broke on September 29, Mrs Stewart got her children ready for the day and travelled to Montrose.
After initial concern over a foetal heart reading was allayed, she was sent home.
Mrs Stewart said she was awoken by contractions and returned to the unit at 1am on September 30, where she gave birth in the pool.
Nevaeh was “quite pale”.
“She was given to me,” she said.
“I was rubbing her back. Quite quickly, a midwife said she would need to cut her cord.
“I’d requested a delayed cord cutting but she wasn’t pinking up like a normal baby, so they cut the cord and took her next door.
“At one point I was able to go in and see her and had a very brief hold of her.”
A doctor came to see Mrs Stewart and informed her of complications.
She agreed resuscitation measures should cease, after seeing her daughter once again.
The inquiry heard the health board use a mobile app called My Birthplace to inform parents-to-be of choices available to them.
Mrs Stewart said the information gave her a “false sense of security” as information relating to community midwifery units and blue-light transfers is “the very last thing you see” in a section regarding emergency circumstances.
Mr Stewart, 30, said the paragraph was “small print” that should have been reinforced during discussions with healthcare staff.
For the health board, Mark Fitzpatrick asked Mrs Stewart whether she was aware she could have gone to Aberdeen to give birth, as Auchenblae is in the NHS Grampian area.
She said she decided on Montrose at 31 weeks, as “things change” during pregnancy and the couple had recently moved to the village from Stonehaven.
Mr Stewart, a logistics chief, said NHS Tayside had conducted an internal Significant Clinical Event Analysis (SCEA) before the decision was taken to pursue an FAI.
“I felt the SCEA almost highlighted more issues and possible faults, for lack of a better word, rather than clearing any doubts we had.
“It became apparent that because Montrose is in NHS Tayside’s area that it’s somehow an emergency response ‘blackspot’.
“I presumed it would be that an emergency response team would have shot out the door and fixed the situation.
“If someone were to choose to have a home birth, it’s my understanding that there would be a 999 response, the exception being a community midwifery unit where there’s no emergency response.
“There is no flying squad in a position to attend any CMU in Scotland.”
The inquiry, before Sheriff Pino di Emidio, continues on Wednesday.
