Inquests

Neonatal care: Example of a Coroner's Prevention of Future Death Report

At the 2025 Inquest into the death of Ida Lock, (born at the Royal Lancaster Infirmary on 9 November 2019) the Coroner James Adeley concluded that Ida's death had been caused by midwives failing to deliver Ida urgently, when she was clearly in distress. He found that her death had been contributed to by the lead midwife's "wholly incompetent failure to provide basic neonatal resuscitation". The evidence was that Ida had died a week after her birth after suffering a serious brain injury due to a lack of oxygen. The Coroner found that Ida's death had been wholly avoidable, and that by the time she had been transferred to a higher dependency unit, at the Royal Preston Hospital, she had suffered the brain injury from which she would not recover. He commented that there had been eight missed opportunities to alter Ida's clinical course.