A baby died after a severe shortage of midwives on a night shift at St Mary’s Hospital in Manchester contributed to his birth being delayed for two days after his mother’s waters broke.

Baby Sparsh Deshmukh contracted the group B strep infection as a result of being left without protection from the amniotic fluid, causing further complications and ultimately his death.

An Article 2 human rights inquest into Sparsh’s death took place at Manchester Coroner’s Court on 14 October 2020, which found his death was contributed to by neglect at the hospital. 

An appalling set of separate issues in the maternity unit caused an induction to deliver Sparsh to be delayed. As well as the severe midwife shortage, this also included staff not following established guidelines and a lack of training for a midwife using a heart rate monitor. These were confirmed by the hospital trust in its internal investigation report.

A case for clinical negligence was brought on behalf of Kavita and Prasad against Manchester University NHS Foundation Trust by Kimberley Peet, a specialist solicitor at law firm JMW, to ensure that the same situation is never repeated. In March 2018 the trust admitted negligently delaying an induction of labour and in January 2020 it admitted that this delay had caused Sparsh’s death. 

St Mary’s Hospital’s own guidelines are that an induction should be carried out within 24-hours of a woman’s waters breaking if labour does not start. However the induction appointment given to Sparsh’s mother Kavita Kalkar for 9am on Sunday 25th June 2017 was nearly 36 hours after her waters had broken. There were then further delays after the induction process eventually started as the labour could not be progressed due to staff shortages in the delivery unit.

Staffing levels on the delivery suite during the night shift following Kavita’s admission to hospital were reduced from the planned fourteen midwives to only nine. At the time of her admission to the maternity ward there were 13 women on the delivery unit with four of those women requiring one-to-one care.

According to the investigation report, at 9.15pm there were 14 women on the delivery unit being cared for by nine midwives. Out of five women being induced awaiting a transfer Kavita was first priority due to it approaching 48 hours since her membranes ruptured. Between this time and 11.45, a woman went into premature labour and needed to be transferred to the delivery unit therefore there was no capacity to accept Kavita due to the reduced number of midwives on the shift.

In the hours leading up to baby Sparsh’s death, Kavita and her husband Prasad Deshmukh repeatedly asked when she would be transferred to the delivery as they were concerned about his safety.

Kavita was finally accepted to the delivery unit at 4.35am. Over the next four hours Sparsh’s heartrate dropped dangerously low. Unfortunately, the midwife responsible for Kavita during this period failed to identify the drop in heart rate and so steps to deliver Sparsh urgently were not taken. The trust investigation report states that the midwife was newly qualified, had only been working on the delivery unit for four months and was not up to date with her training on the use of electronic fetal monitoring. The training she had received consisted of less than one hour reviewing the guidelines. Due to the staff shortages she had no senior midwife to support her.

Following review by a doctor at 8.35am Kavita was taken for an emergency C-section. When Sparsh was born he was unresponsive. Following extensive resuscitation he showed some signs of life but sadly these could not be sustained and he died at 37 minutes old. 

Kavita, a travel consultant who lives in Wigan with Prasad, commented: “We welcome the conclusion of the inquest with a finding of neglect, which follows more than three years of Prasad and I searching for answers as to why this was allowed to happen to our baby boy and how we can protect other families from suffering a similar preventable tragedy.

“We have had to relive the episode so many times and each time it feels as though Sparsh has died all over again. We will never be able to move on from the pain of losing him, but we hope we can finally begin to live again for the sake of our precious daughter Trushna, who has brought light to us at an incredibly dark time.

“We can only hope that our case serves as a warning of the truly horrific consequences midwife shortages can have.”

Kimberley Peet, a clinical negligence solicitor at law firm JMW, who is representing Kavita and Prasad, commented: “The finding that Sparsh’s death was contributed to by neglect by the coroner was entirely right and brings some comfort to Kavita and Prasad that justice has been served.

“The appalling standard of care provided to Kavita was inexcusable and has no place in a modern day health service. If guidelines had been followed, adequate training had been provided to staff and there had been an appropriate number of midwives on duty, then Sparsh’s tragic death would have been avoided and Kavita and Prasad’s family would be intact. They have shown unbelievable strength throughout to stop this from happening again and I sincerely hope lessons have been learned.”

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