Birmingham boy’s ‘avoidable’ breech birth contributed to death

A two-year-old boy’s death could have been avoided if his breech birth had not been delayed, a coroner has said.

Mohammed Ismail Khan died on 30 October 2024 from a respiratory infection due to the effects of a brain injury sustained during a breech delivery, an inquest ruled.

Emma Brown, area coroner for Birmingham and Solihull, said the youngster’s “catastrophic” brain injury suffered during his “avoidable delay” in breech delivery on 6 September 2022 led to his death from the infection two years later.

She said the baby’s mother, Mrs Khan, had been discharged from Birmingham Heartlands Hospital just a few hours before his birth despite “multiple antenatal risk factors”.

In the prevention of future deaths report, Ms Brown said Mrs Khan should have remained in hospital until delivery, and as a consequence the emergency response when spontaneous labour occurred was “delayed and suboptimal.”

A West Midlands Ambulance Service (WMAS) investigation found clinicians attending the emergency birth had no prior experience of breech deliveries.

Findings concluded that during labour Ms Khan, who was 36 weeks pregnant, was asked to position on all fours rather than standing as the baby was being born feet first.

This “progressed delivery a little” but visible parts of the baby showed signs of hypoxia, and clinicians then followed a “hands off” approach, and sought advice from the regional trauma desk who advised rapid transfer to hospital and had pre-alerted Birmingham Heartlands Hospital, the report said.

Mohammed was born in hospital with no heart rate and no respiratory effort, the report added, and although he responded to resuscitation, he had suffered profound severe brain damage.

The WMAS investigation concluded guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk, “as the clinicians did not appreciate delivery was delayed and intervention to aid delivery should be attempted”.

A WMAS clinical manager maternity lead said it was “not mandatory” for paramedics to receive specific training on obstetric emergencies, including breech delivery.

Maternity and obstetric care make up 3% of emergency ambulance responses, according to the WMAS clinical manager maternity lead.

WMAS said in its report that it had purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation.

But Ms Brown said resourcing is such that it had not been possible for all paramedics to receive this additional training, stating that less than a third of paramedics with WMAS had completed the online course.

She said the absence of any mandatory training on obstetric emergencies was putting lives at risk, and was an added factor in the death of Mohammed at Birmingham Children’s Hospital two years later.

WMAS, NHS Birmingham and Solihull ICB, NHS Black Country ICB, NHS Coventry and Warwickshire ICB, NHS Herefordshire and Worcestershire ICB, NHS Shropshire, Telford and Wrekin ICB, NHS Staffordshire and Stoke-on-Trent ICB and the Association of Ambulance Chief Executive, have until 11 November to respond.

Each of the above has been approached by the BBC for comment.

In a statement, WMAS said: “We would again like to apologise to the family of Mohammed Ismail Khan and offer our condolences.”

WMAS said it undertook a serious incident investigation, which was shared with Mohammed’s family, and since 2022 it had made a number of changes to try and make sure something like this never happened again.

“We note the preventing future deaths report that the coroner has issued and will respond to it fully within the timeframe,” it added.