Premature baby died after CPR not attempted, inquest finds

Emanuel Anton was born and died on Friday, March 3, 2023, and he was described as 'extremely premature'.

On the morning of his birth, his mother Geanina Anton felt severe pain when she went to the bathroom in the early hours.

Blackburn Town Hall heard she had had three healthy pregnancies before Emanuel, so immediately knew something was wrong.

She had previously been told her placenta was lying low which could create possible complications in the pregnancy.

Geanina was taken to Royal Blackburn Hospital by her husband, where doctors then rang for an ambulance to transfer her to Burnley General Hospital.

She arrived at 7.50am, was seen by a doctor at 7.55am, and Emanuel was born at 8.03am.

However, her gestation period was believed to be only 22 weeks, just over half of the time normal babies are born at full term - 40 weeks.

The court heard Emanuel was also born with the umbilical cord wrapped around his neck, and with the amniotic sack still intact.

Dr Naomi Todd observed Geanina had lost around a litre of blood, and took her for an emergency operation in order to remove her placenta, in fear of her haemorrhaging. 

However whilst Geanina was being attended to, Emanuel had died shortly after he was born.

Geanina said: "I was in a state of shock, losing a lot of blood from the ordeal of the events and in great pain.

"I can't remember much, only that I felt like I needed to push. I held him on my chest for a few moments until I was taken away. 

"Afterwards my husband and I were put into a room and were told he had gone."

An investigation by East Lancashire Hospitals NHS Trust found the data around Geanina's gestation period at her last scan on February 23 was listed wrong due to 'human error'.

Geanina's midwives had scanned the anatomy of the baby due to her placenta complications, and not noted the correct gestation period.

This meant Geanina was actually 23 weeks pregnant when Emanuel was born.

New 2022 neonatology guidelines state that although babies previously born before 24 weeks had a low chance of surviving, there is now a "grey area" as more and more babies ranging from 22 to 26 weeks have begun to survive.

This meant those guidelines recommended babies with a gestation period of 22 weeks should have resuscitation attempted, but this was not attempted on Emanuel.

Coroner Richard Taylor asked Dr Todd why resuscitation had not occurred, and why neonatal consultants at the hospital were not called.

Dr Todd answered that there was not enough time, and the focus was more drawn to Geanina as she was considered extremely unstable.

She said: "I could see the mother was very distressed and in pain, and I explained that she could be in labour.

"I told her I needed to perform an examination, but Emanuel's head had already begun to show which meant I was unable to.

"It all happened in a very short time."

The investigation by ELHT stated that since Emanuel's death, they are now testing out automatic updates of gestation periods in each expectant mother's scans, instead of relying on human input.

They are also informing members of staff of updated guidance from different medical departments, with education days to ensure care is up to date with the newest recommendations. 

The court also heard even if the gestation period on Geanina's scan was correct, and if neonatology consultants were called, Emanuel's survival was still not guaranteed. 

Coroner Richard Taylor gave a narrative conclusion of death.

He said: "I offer my sincere condolences for your loss. I like families to leave inquests with their questions answered, and I hope that you have had yours.

"It would be too easy to say that Emanuel died of natural causes, but I think it is more complicated than that.

"I record that Emanuel died from extreme prematurity, but also that his anticipated birth date had not been recorded accurately, and doctors did not have enough information on whether he should have been resuscitated or not."