Inquest into the death of Baby J

0y · Female·premature delivery; extreme prematurity

A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a live infant (estimated 21-22 weeks gestation, weighing 515g) was unexpectedly delivered at 02:45. The attending midwife, Carrie Williams, was the sole attendant. She contacted the obstetric doctor by phone, reporting the baby was alive with good vital signs. The doctor responded with apparent indifference ('So? I will see her in the morning') and provided no clinical direction. The midwife placed the infant in warm bedding and monitored it. The baby died 80 minutes later from extreme prematurity. The coroner found the doctor failed to recognise his duty of care to the born infant, leading to a 'responsibility vacuum'. While resuscitation would likely have been futile, the doctor should have attended, assessed viability, and managed comfort care. Key deficits included: no forewarning to nursing staff of live birth possibility, no protocols in place, absence of medical direction, and failure to escalate care. The coroner recommended protocols be established for managing unexpected live births following terminations.