A fatal accident inquiry has determined that the deaths of three newborn babies in Scottish hospitals between 2019 and 2021 could have been prevented with reasonable precautions. The investigation, led by Sheriff Principal Aisha Anwar KC, highlighted system failures and lapses in medical guidance that played a significant role in the tragic outcomes.
Failures in the System
The deaths of Leo Lamont, Ellie McCormick, and Mira-Belle Bosch occurred under circumstances that the inquiry found to be avoidable. The report criticized a lack of effective risk assessment tools, inadequate guidance for midwives in identifying preterm labor, and failures in patient record-keeping systems.
Sheriff Anwar made 11 recommendations aimed at improving maternity care across Scotland, including:
- Implementing a “trigger list” to help midwives assess early labor symptoms.
- Enhancing electronic patient records to flag high-risk pregnancies more effectively.
- Establishing a direct emergency telephone line to each maternity unit for ambulance crews.
Families of the deceased infants have called for urgent action to ensure these recommendations are implemented.
Missed Warnings in Leo Lamont’s Case
Leo Lamont was born at just 27 weeks gestation on February 15, 2019, after his mother, Nadine Rooney, experienced severe back pain. She contacted the Princess Royal Maternity Hospital in Glasgow for advice but was advised to take painkillers instead of being instructed to go to the hospital.
Less than two hours later, she gave birth at home, and by the time paramedics arrived, her baby was struggling to breathe. He was later pronounced dead at University Hospital Monklands. The inquiry concluded that had Ms. Rooney been told to seek medical attention immediately, her son’s life could have been saved.
Ellie McCormick: Delayed Response Proved Fatal
Ellie McCormick’s mother, Nicola, was classified as a high-risk pregnancy due to a high BMI. She had previously reported reduced fetal movement and bleeding, yet no steps were taken beyond routine monitoring.
On March 4, 2019, she called Wishaw General Hospital reporting contractions but was again advised to take painkillers and call back if symptoms persisted. Hours later, she was rushed to the hospital for an emergency caesarean, but Ellie had already suffered severe oxygen deprivation and died within five hours of birth.
Medical experts testified that if Ms. McCormick had been advised to go to the hospital when she first called, Ellie’s death could have been prevented.
A Desperate Struggle for Help in Mira-Belle Bosch’s Case
Mira-Belle Bosch was born on July 2, 2021, at Wishaw General Hospital, but died 12 hours later due to a brain injury caused by oxygen deprivation during labor.
Her mother, Rozelle Bosch, reported her waters breaking on June 30 and experienced contractions, yet she was sent home after a hospital visit. The following day, she called again but was told to remain at home.
When she eventually gave birth, paramedics struggled to get the necessary medical assistance. Despite making five calls to Wishaw General, they received no response. The inquiry found that staff had relied too heavily on NHS Lanarkshire’s outdated guidance, which recommended waiting 47 hours before inducing labor. Sheriff Anwar ruled that Mira-Belle’s death could have been prevented had labor been induced 24 hours after her waters broke.
Families Demand Change
The families of the infants have expressed profound grief and frustration over the failures that led to their children’s deaths.
Ellie McCormick’s family described the situation as a “catalogue of errors” and said they were shocked by the extent of both individual and systemic failures.
Leo Lamont’s family echoed similar sentiments, urging medical professionals to learn from these tragedies.
“The scale of failures was unimaginable,” the McCormick family stated. “We hope all the recommendations will be implemented so no other families have to endure what we have.”
Recommendations for the Future
Sheriff Anwar emphasized the importance of swift changes to Scotland’s maternity care system. Among her key recommendations:
| Recommendation | Purpose |
|---|---|
| Creation of a “trigger list” | Helps midwives recognize early labor symptoms |
| Improved electronic records | Enhances alerts for high-risk pregnancies |
| Direct telephone line to hospitals | Ensures paramedics can reach maternity units instantly |
The Crown Office hopes the findings will provide answers for the grieving families while ensuring future cases are handled more effectively.
Sheriff Anwar acknowledged the immense pain the families have endured, saying, “The death of a child is an unimaginable and deeply painful event in any parent’s life; one from which it is undoubtedly difficult to recover.”
With these findings now public, affected families and advocacy groups will continue pushing for reforms to ensure no more newborns suffer preventable deaths due to medical oversight.
