Jayden Astley (A minor by his father and litigation friend Craig Astley) v Lancashire Teaching Hospitals NHS Foundation Trust

In a clinical negligence claim concerning intrapartum monitoring, a failure to identify fetal heart-rate abnormalities constitutes a breach where competent intermittent auscultation should have detected them. Complicated variable decelerations caused by cord compression should prompt continuous cardiotocography and urgent obstetric review. The assessment of blood-stained liquor remains a matter for the experienced midwife’s clinical judgment where it is distinguishable from fresh bleeding and no guideline or established practice requires automatic conversion to continuous monitoring. Causation is established where timely detection would probably have led to delivery before the onset of irreversible injury.

The claimant sustained severe brain injury following acute, profound hypoxia-ischaemia during his birth. The claim was tried as a split trial on breach of duty and causation, with damages to be assessed later if liability was established.

The claimant alleged failures to respond to blood-stained liquor, to monitor the fetal heart accurately, and to identify variable decelerations and subsequent bradycardia. The central questions were whether the midwife’s monitoring fell below the required standard and whether competent monitoring and appropriate obstetric intervention would have resulted in delivery before permanent brain damage occurred.

1. Judgment for the claimant. The agreed evidence established that acute profound hypoxia-ischaemia began at about 15:03, that profound bradycardia then existed, and that the fetal heart-rate recordings from about 15:05 onwards could not be accurate. Those erroneous recordings constituted a breach of duty.
2. The court found that, from at least 14:45, complicated variable decelerations caused by umbilical cord compression would have occurred following most contractions. Competent intermittent auscultation should have detected them. The failure to do so was a breach and should have led to continuous cardiotocography and an emergency call for an obstetrician. The decelerations were probably present even earlier.
3. The court rejected the allegation that the observation of normal blood-stained liquor itself required conversion to continuous monitoring or immediate obstetric review. An experienced midwife should distinguish normal blood staining from fresh bleeding or bleeding suggestive of placental abruption. Neither the NICE guideline nor local guidelines required monitoring to be converted after a specified period of normal blood staining, and the issue remained one of clinical judgment.
4. On causation, earlier detection would probably have resulted in preparation for instrumental delivery, an obstetric review and delivery by about 15:08 at the latest. This would have restored cerebral circulation before permanent neurological injury occurred.
5. The court also found that the late fetal heart-rate entries had been fabricated once the midwife believed delivery was imminent, and that the assisting midwife could not rely on the absence of a recorded concern as demonstrating that the fetal heart was reassuring.