Poppy Harris: Milton Keynes coroner warns over forceps use

A coroner has warned over the use of a type of forceps following the death of a four-month-old baby who suffered a spinal injury during birth.

Poppy Harris was born by the use of Kielland's forceps at Milton Keynes Hospital in November but died in March.

Senior coroner Tom Osborne called for the hospital to urgently review the forceps' use "and decide that they should no longer be used".

The hospital has suspended its use of them.

Poppy was born on 23 November 2020 following a "protracted labour", said Mr Osborne, and she was delivered by the use of Kielland's forceps.

"She was transferred to John Radcliffe Hospital in Oxford where it was discovered that she had suffered a spinal cord injury and despite all efforts and care she died on 24 March," he said.

The inquest concluded that Poppy "died as a result of a spinal cord injury caused by the inappropriate use of Kielland's forceps during delivery for which her mother had not given informed consent".

Mr Osborne said he was concerned Poppy's mother did not have a birth plan when she came into the hospital, nor was there an attempt by midwives to complete one.

"There was therefore no indication as to her preferences for treatment and care throughout her labour," he said.

Mr Osborne added: "Poppy was delivered by the use of Kielland's forceps that resulted in a catastrophic spinal cord injury. I believe the hospital should carry out an urgent review of the use of Kielland's forceps and decide that they should no longer be used."

Mr Osborne also wrote about his concerns to the Royal College of Obstetricians and Gynaecologists (RCOG), and a spokeswoman said: "The loss of a baby is a devastating tragedy and the RCOG extends its deepest condolences to all those affected.

"We have received the coroner's report and will be responding in due course."

Tim Deeming, solicitor from Tees Law, who are representing the family, said they share the coroner's concerns.

"We look forward to considering the response to his prevention of future deaths report from both Milton Keynes Hospital as well as the RCOG so that widescale effective lessons and improvements can be learnt.

"As the coroner reflected, every time Kielland forceps are picked up we would like the clinicians to think of Poppy."

Milton Keynes University Hospital (MKUH) medical director, Dr Ian Reckless, said: "I would like to say how very sorry I am to Poppy's parents.

"The death of a child is immeasurably painful and I am deeply sorry for their loss and the pain and suffering they have endured."

Dr Reckless said birth plans were already widely used at MKUH, although women are not required to make them.

He added: "Although currently used in obstetric units across the country, the use of Keilland's forceps is currently suspended at MKUH.

"Outside the requirements of the two matters in the preventing future death report, we will also work with women and families on how we ask women in labour for their consent; and are currently developing new forms for clinicians to ensure consent is recorded in a standardised and thorough way."

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