Dad claims 'systemic failures' in hospital where newborn died, FAI hears

WARNING: This article contains content some readers may find distressing.

A Lanarkshire dad claims there was a "systematic failure" at the hospital where his baby died, just hours after being born.

Eckhardt Bosch made the statement while giving evidence at a probe into daughter Mirabelle Bosch’s death.

Mirabelle died at Wishaw General Hospital 12 hours and one minute after being born on July 2 2021.

The fatal accident inquiry at Glasgow Sheriff Court will also look into the deaths of Ellie McCormick and Leo Lamont.

Ellie also died at Wishaw General Hospital five hours after being born on March 5 2019.

Leo died at University Hospital Monklands on February 15 2019 when he was two hours old.

'Unimaginable and deep tragedy'

Sheriff Principal Aisha Anwar opened proceedings by stating: "The death of a child is an unimaginable and deeply tragic event in any parent’s life.

"I would like to commence this chapter of the Inquiry as I commenced the first preliminary hearing, by again offering my deepest condolences to the parents of each child."

Mirabelle's mum Rozelle Bosch, 34, stated that she was told at a 31 week scan that her daughter was in a breach position.

She was then informed at a 34-week scan that Mirabelle had moved to a cephalic position.

Mrs Bosch's waters broke on June 30 2021 but was discharged from hospital.

She stated that midwife Michelle Tannahill carried out basic checks on her and found that Mirabell was "less engaged."

Mrs Bosch reported having three to four contractions in 10 minutes and then a lapse of 20 minutes.

She stated that Miss Tannahill gave her an option of a second scan if "things changed."

Mrs Bosch and her husband Eckhardt Bosch were handed a written note with an induction day of July 2 2021.

The note also asked Mrs Bosch to look for colour of amniotic fluid, foetal movement and signs of infection.

'Very anxious'

Mrs Bosch recalled being "very anxious" following the visit and made a phone call to the maternity triage.

Mrs Bosch said: "I was told if I can't handle the pain then I should come in.

"I was told that I sounded calm enough so I should be fine."

Fiscal Lisa Gillespie KC asked Mrs Bosch if the midwife told her about coming to the hospital to be assessed.

She replied: "No, I would have taken any opportunity to go to the hospital.

"The midwife I spoke to said you felt comfortable at home today."

Miss Gillespie: "Did you say that?"

Mrs Bosch: "I did recall saying it but my to my mind I was having a normal birth and did not have contractions that were excruciating or taking my breath away."

The witness later stated: "If I didn't follow the advice I would probably have sat in the hospital."

'Undiagnosed breach baby'

Mirabelle was born after being rushed to hospital from their home in Shotts, Lanarkshire, in the early morning of July 2 2021.

Mirabelle's dad Eckhardt told the hearing that he believes his daughter was an "undiagnosed breach baby."

He said: "We were told Roselle was healthy and Mirabell was healthy.

"I think this was a lie and the consequences have me standing here today.

"In all the scans, Mirabelle was not red flagged and was seen as normal.

"Me and my wife were calm due to the information put as it was.

"Everything will be fine rings in my ears."

Mr Bosch also addressed the Scottish Ambulance Service which he described as "disappointing."

He stated that they believed they were "misguided and misled".

'Systemic failure'

Mr Bosch added that the ambulance service was also "incompetent to deal with this situation."

He stated that it was the "wrong" how staff moved his wife through the hospital.

Mr Bosch also claimed that the medical approach of not touching the baby in breach "lacked creativity" and was "part of the problem."

Mr Bosch spoke about the earlier handwritten letter given to them on June 30 which stated that Mrs Bosch would be induced on July 7.

Mr Bosch stated that the note "made things confusing" and then pointed out that Mirabelle was "already dead" by that date.

He later said: "I'm of the strong opinion that it is unethical to send mothers home when waters have broken.

"We had to travel quite far away from Wishaw Hospital - it is a clear systematic failure on a large scale.

"Thinking about what happened, one thing led to the next - the system was not able to save us or Mirabell.

"Mirabelle was on the brink of death and there was a lack of getting stuff done - they were trained to do it but it wasn't there.

"I believe we were misled due to incorrect and inadequate guidance from medical staff on an individual basis and the whole system."

Mr Bosch lastly asked the court to look at the lack of diagnosis of Mirabell being breach, the lack of advice when they entered the hospital after Mrs Bosch waters broke and the way in which paramedics delivered his daughter.

'It is always possible'

Mrs Bosch's midwife Lesley Nicolson gave evidence at the hearing.

She stated that Mirabelle presented in the breach position at Mrs Bosch's 31-week appointment but this changed to cephalic at her 37-week appointment.

Miss Gillespie asked: "Is it possible your assessments of Mirabelle's presentation between these dates been mistaken and having been breach at 31 weeks, she never moved to a cephalic presentation?"

Miss Nicolson replied: "It is always possible."

A joint minute of agreed evidence was read to the hearing about the circumstances leading up to Mirabelle's death.

An ambulance was called for and attended near 11pm on July 1 2021.

Mirabelle was found to be breach and was pink in colour.

Paramedics reported complications with the birth to the control room and were told that all that could be done was send another crew.

Five call attempts were made to Wishaw's maternity triage which was then answered at 11.40pm.

Mirabelle's arms and shoulders were successfully delivered but her head remained undelivered.

A doctor advised paramedics to take Mrs Bosch to hospital as she required expert personnel.

The doctor asked to be removed from loudspeaker that there was a low chance of survival due to the time that had passed.

Life support turned off

Mirabelle was delivered at hospital before 12.30am where she was stated to be white and floppy before she was incubated.

She was noted not to gasp or cry or open her eye and did not respond to stimuli.

Mirabelle was found to have suffered a brain injury due to lack of oxygen.

Life support and her ventilator was turned off at 12.15pm that day while she was held by Mrs Bosch.

Her cause of death was determined as breach home delivery, head entrapment.

The death sparked a review of the Lanarkshire Health Board and eight recommendations were made - six of which have been implemented to date.

The inquiry continues before Sheriff Principal Anwar.

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