Family Slam Postcode Lottery Effect after Death of Their Baby

Following an inquest into the death of Molly Dimmock held at Beaconsfield Court, last week, the coroner considers there to be a risk of further deaths owing to lack of national guidance

Molly Dimmock died shortly following her birth aged just 34 minutes on 25 June 2020. An inquest into the circumstances of her death before Senior Coroner Crispin Butler found that Buckinghamshire Healthcare Trust and staff at Stoke Mandeville Hospital had underestimated her size and failed to identify accelerated foetal growth when her mother Charlotte attended for her 36-week ultrasound scan. As a result, Charlotte was not warned about the heightened risks of carrying a Large for Gestational Age (LGA) Baby and in particular the risk of shoulder dystocia (a birth injury during which one or both of a baby’s shoulders becomes stuck inside the mother’s pelvis during delivery).

The coroner found that the first opportunity for Charlotte to discuss her birth options with a doctor was when she was in established labour on 25 June 2020, and on that occasion she was again not warned about the risks of carrying a LGA baby nor the risk of shoulder dystocia. Despite asking for a caesarean section, the clinicians delivering Molly did not offer Charlotte this option.

The coroner drew attention to the absence of a national definition of LGA baby and the difficulties this caused clinicians, and consequential risks to mothers and babies, having heard evidence that some Trusts define this as babies above the 90th centile, whereas Buckinghamshire Healthcare Trust considered only babies above the 95th centile to be LGA. He noted that if Molly’s size been correctly identified then the care pathway would have been different for her, her parents and her clinicians.

Using his powers under Regulation 28 Coroners (Inquests) Regulations 2013, the coroner sent a report to the National Institute for Clinical Excellence, the Royal College of Obstetricians and Gynaecologists, NHS England and Buckinghamshire Healthcare Trust outlining his concerns that there remains a continuing risk of future deaths to both mothers and babies as a result of the absence of a definition of LGA baby.

Molly’s parents, Charlotte and Luke Dimmock, said: “We are pleased that the coroner is using his power to highlight the problem of the postcode lottery that currently exists. If you currently, for instance, live in Reading and your babies estimated foetal weight is on the 90th percentile mothers, will be given delivery options around having a large gestational baby. However, if you live in and around Aylesbury, a mother won’t be given those options unless their baby is on or above the 95th percentile. The pain and suffering Molly’s loss has caused her parents and greater families is unimaginable. Had the 36-week scan been read correctly Molly should have been then correctly identified as a large gestational baby, the correct referrals would have been made this would have led to proper discussions taking place about modes of delivery for Molly and her mother.

“One question that still remains unanswered is why Molly was not delivered by caesarean section when her mother asked for that method of delivery. Whilst we accept nothing will ever bring our precious Molly back to us, it is our hope and prayers that the findings of this inquest and the coroner’s actions will help prevent other parents from suffering a loss like ours and that they will be able to enjoy watching their babies grow and develop, as we are not.”

Speaking about the coroner’s conclusions, Sonia Rani, Medical Negligence Solicitor at Hodge Jones & Allen said: “Molly’s loss is tragic for both Charlotte and her family and it is lamentable that the clinicians involved in Charlotte’s care at Buckinghamshire Healthcare NHS Trust underestimated Molly’s estimated foetal weight and failed to identify accelerated foetal growth at Charlotte’s 36-week scan. As a result, Molly’s parents were not warned about the risks in carrying a Large for Gestational Age (LGA) Baby nor were they counselled on the risks of Shoulder Dystocia. Had Molly’s size been identified before the decision making for the mode of delivery, then the pathway would have been different for Molly. We welcome the coroner’s findings that there is no national guidance which defines an LGA Baby and in this particular case the lack of a standard accepted definition of an LGA baby triggered the issues highlighted in Molly’s sad case. Following Molly’s inquest, we hope that an accepted definition of an LGA baby is adopted by all Trusts across NHS England which would prevent future deaths from occurring and minimise the risk to both mother and baby.”

Molly Dimmock’s family are represented by Sonia Rani, Medical Negligence Solicitor, Hodge Jones & Allen and Emma- Louise Fenelon, Barrister of 1 Crown Office Row.

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