Sam Harmel secures finding of Neglect and systemic failures in an Article 2 Inquest into the death of baby Sparsh Deshmukh at St Mary’s Hospital, Manchester.

Kavita Kalkar v Manchester University NHS Foundation Trust

Sam Harmel represented the parents of baby Sparsh Deshmukh at an Inquest into his death.  Baby Sparsh died shortly after he was born following considerable delays and inadequate care at St Mary’s Hospital.

There was a catalogue of significant systemic and individual failures that contributed to baby Sparsh’s death.  These included a considerable delay in inducing his mother (Mrs Kalkar) after her waters broke, delays in transferring her to a delivery unit, delays in monitoring the fetal heart rate and the misreading of the fetal heart rate scan by a junior, unsupervised midwife. 

The hospital’s own guidelines state that induction of labour should start within 24 hours of a woman’s waters breaking.  However, induction was not commenced until almost 36 hours after Mrs Kalkar’s waters broke and there were considerable further delays until she was admitted to the delivery unit. This meant that in total there was a 21 hour delay between when Mrs Kalkar should have been admitted to the delivery unit and when she actually was.

The understaffing of the maternity unit at this time impacted upon the care provided. The number of midwives on the ward on the night of Mrs Kalkar’s labour was reduced from 14 to 9.  This led to a delay in Mrs Kalkar being admitted to the delivery unit which meant that she was not monitored and therefore signs that baby Sparsh had an infection and needed to be delivered immediately, were not picked up on.  Those signs were apparent when fetal heart rate monitoring was commenced, however the midwife caring for Mrs Kalkar failed to interpret the results correctly which was a further missed opportunity.

The Hospital Trust accepted that there were gross failures in their care of Mrs Kalkar.

The Coroner concluded that Sparsh died of natural causes contributed to by neglect.  The collective systemic and individual failures contributed to the death.

Sam Harmel was instructed by Kimberley Peet from JMW Solicitors.


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