In a Prevention of Future Deaths report, coroner James Adeley said there had been ‘multiple missed opportunities to avoid Ida's death on 16 November 2019.
Coroner Adeley said: ‘Ida was a normal child whose death was caused by a lack of oxygen during her delivery that occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress and contributed to by the lead midwife‘s wholly incompetent failure to provide basic neonatal resuscitation for Ida during the first three-and-a-half minutes of her life that further contributed to Ida's brain damage from which she died on 16 November 2019 at the Royal Preston Hospital neonatal intensive care unit.'
The coroner noted a ‘deep seated and endemic culture of defensiveness in respect of maternity incidents at the trust' and failure to learn from criticisms made in a 2015 investigation.
The BBC has also revealed the trust has received hundreds of thousands of pounds in payments for providing good care under Under the Maternity Incentive Scheme run by NHS Resolution. One claim was later reviewed following a critical CQC inspection.
University Hospitals of Morecambe Bay NHS Foundation Trust issued an apology to Ida's family adding it had failed her and her family.
The trust said it had made a number of improvements since the inquest, including: rapid reviews following incidents; appointing an Independent Senior Advocate for families; daily triage meetings to review all incidents from the previous 24 hours; additional workforce training; and informing families of the completion of MNSI (Maternity and Newborn Safety Investigations) reports or a Root Cause Analysis.
Tabetha Darmon, chief nursing officer, University Hospitals of Morecambe Bay NHS Foundation Trust, said: ‘We are carefully reviewing the learning identified to ensure that we do everything we can to prevent this from happening to another family.
‘There is still a lot of work to be done, and our teams remain committed to continuously improving maternity services for women, pregnant people, and families across Morecambe Bay.'
