“Numerous Mistakes” by NHS Trust Lead to Baby’s Death During Breech Birth

Frimley Park Hospital, Portsmouth admitted mistakes in failing to recognise a breech birth or to act appropriately once noted, leading to the death of baby Theo Ellis from oxygen starvation in April 2019.

This comes at a time when East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals Trust are under scrutiny over similarly concerning maternity care shortcomings.

According to an independent investigation carried out by the HSIB (Hospital Safety Investigation Board), the maternity staff at Frimley Park Hospital are culpable for a series of medical mistakes—including questionable processes, miscommunication, delays in care, and management issues.

Mrs Ellis, the mother of baby Theo commented:

I walked in with a healthy baby. I’d looked after him for nine months and they killed him in the process of giving birth. The hospital gets to write that he was stillborn, which obviously is a huge benefit to them, because the coroner can’t get involved, which to me is just staggering.

The NHS Trust initially classed the incident as a stillbirth but has now admitted their mistakes following the HSIB report and legal action by the baby’s parents, Mr and Mrs Ellis.

The “Chaotic” Events

In an interview with The Independent, Mrs Ellis recounted the events that transpired on that fateful day.

When he was half delivered, he was still alive, and he had a heartbeat. But then at some point during that process, he stopped having a heartbeat and died. When that was exactly, no one knows because they weren’t properly checking and they didn’t realise his condition was actually deteriorating.

“It is a never-ending kind of torture I guess I will have to live with. You just don’t realise until it happens to you how many babies there are that should be here but aren’t because of these dreadful situations that are going on.”

Mrs Ellis’ accounts and the HSIB report revealed several mistakes by the staff at the NHS maternity unit during the “chaotic” and fatal breech birth. The errors began in the weeks leading to baby Theo Ellis birth. Ultrasound scans that could have helped diagnose the breech were missed.

The mistakes continued when Mrs Ellis arrived at Frimley Park Hospital and the midwives failed to carry out recommended admission checks, which may have allowed them to detect the breech position. It was not until Mrs Ellis was in advanced labour that the issue was recognised.

According to findings by the HSIB investigation, senior staff were not called to deliver the baby when the breech position was discovered—suggesting that the hospital did not declare the high-risk situation as an emergency.

The report said:

The majority of staff leading the delivery were junior or new in their roles … there was not enough expertise in the room to manage the delivery.

 “The time from delivery of the umbilicus to delivery of the head would have been at least 13 minutes. The baby’s head was delivered … at 18.13 hours, seven minutes after the baby’s arms had been delivered.”

It added, “The HSIB clinical panel felt that the delivery of the baby was significantly delayed, and that the delivery appeared disjointed…was no perceived sense of urgency or recognition of the situation and no clear leadership.”

Although Laura Ellis had requested a birth plan that reduced the number of people in the delivery room, the staff failed to adapt to the emergency situation by discussing the circumstances with the mother and deviating from the plan. This meant that a paediatrician was forced to stand outside the room while the junior staff attempted to deliver the baby.

Mrs Ellis said:

I really had no idea what was going on. This was so far from what I had envisaged being my birth, that obviously, if anyone had asked me, I would have said ‘I want whoever is most experienced here to help with this situation’.

“I want what is best for my baby. But for some reason, they never spoke to me about that. And instead asked experienced staff to wait outside the room. I just feel furious about that. Why didn’t they ask me or realise this is not the best thing for the baby?”

Attempts to resuscitate baby Theo were then hampered when the oxygen cylinder ran out. The experience was described as “chaotic”—including the placement of equipment on the floor.

A Grieving Mother’s Loss of Trust in the NHS

Mrs Ellis commented:

 “When you’re pregnant you can live in a kind of blissful ignorance that when you go into hospital, you’re going into the safest place possible and they’re going to really look after your baby and everything’s going to be done for them when actually, we found that really wasn’t the case.

“It took way too long to realise that Theo was breech and by the time they realised, they could see his testes, so then their options were very limited to what they could do.”


She goes on to say that she is not angry at the people present at the tragic delivery, but there should have been processes to stop the errors from happening.

After losing confidence in the NHS from her traumatic experience and loss of baby Theo, Laura Ellis went on to deliver another baby (Josh) privately.

Implemented Changes

In response to the HSIB report, a spokesperson for Frimley Park Hospital admitted that:

 “This is a tragic case and we are very sorry that our care for Mrs Ellis and baby Theo failed to meet the standards we expect of our maternity services.

“We have fully accepted and taken on board the findings and recommendations in the investigation report, and we met with Mr and Mrs Ellis to express our condolences for their sad loss and to apologise for the trust’s failings in care.”

We have discussed the findings of the HSIB report with Mr and Mrs Ellis and shared with them the steps that we have taken aimed at preventing anything like this from happening again.”

Some of these changes mentioned include:

  • Having an experienced consultant at every breech birth,
  • Ensuring expectant mothers are properly examined on arrival to the maternity unit and
  • Creating a full emergency response for deliveries in breech positions.

Although the NHS Trust has admitted liability for the death of baby Theo, an agreement for legal settlement has yet to be reached.

Guidance on Breech Birth By the Royal College of Obstetricians and Gynaecologists (RCOG)

Accourding to recent guidance by the RCOG, If a baby is breech at 36 weeks of pregnancy, a healthcare professional should discuss the following options with the mother:

• trying to turn your baby in the uterus into the head-first position by external cephalic version (ECV)

• planned caesarean section

• planned vaginal breech birth.

The RCOG leaflet also mentions the presence of a pediatrician:

“In some circumstances, for example, if there are concerns about your baby’s heart rate or if your labour is not progressing, you may need an emergency caesarean section during labour. A paediatrician (a doctor who specialises in the care of babies, children and teenagers) will attend the birth to check your baby is doing well.”

The risk factors associated with a breech pregnancy

Although only 3-4% of pregnancies are breech, medical professionals need to be aware of the risk factors which increase the likelihood of a breech birth. These include:

  • a first pregnancy
  • the placenta is in a low-lying position (also known as placenta praevia)
  • too much or too little fluid (amniotic fluid) around the baby
  • having more than one baby.

(Source: https://www.rcog.org.uk/en/patients/patient-leaflets/breech-baby-at-the-end-of-pregnancy/)

Medical negligence associated with a breech pregnancy could include:

  • the failure to diagnose a breech pregnancy i.e. regular scans,  abdominal palpation and vaginal examinations not were conducted or conducted negligently
  • the fetal-heart rate not monitored throughout labour
  • the failure of a maternity unit to provide skilled supervision and protocols for the management of vaginal breech birth where the mother is admitted in advanced labour.  
  • The failure to conduct a planned vaginal breech delivery in a hospital with facilities for immediate caesarean section.
  • Medical staff attending the birth were not sufficiently aware of the increased risk of asphyxiation when the baby is breech, particularly with the increased risk of cord prolapse.

Contact our birth injury claims experts

Because pregnancy and childbirth negligence is a complex area it is always recommended to discuss your case with specialist birth injury solicitors with experience of successfully pursuing a variety of claims such as those relating to physical injuries, surgical errors and negligence relating to breech or complex births, Caesarean sections, failures incorrectly monitoring health or interpreting scans, or oxygen deprivation and brain injury to a baby, including cerebral palsy.

Devonshires Claims provides a No Win No Fee’ agreement for birth injury claims, which means that there are no upfront costs* to start your compensation claim. For more information on making a private or NHS maternity negligence claim or to start your free case evaluation contact our birth injury solicitors today on 0333 900 8787, email admin@devonshiresclaims.co.uk or complete our online form.

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