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Y v York Teaching Hospital NHS Foundation Trust

By Clare Gooch

Having a baby can be both exciting but also nerve wracking, especially for first time parents. There is a lot of pressure on parents to make the right call at the right time. If a parent is not adequately supported or actually given the wrong ante-natal advice, this can have catastrophic consequences for all involved.

Since April 2021 Tamlin Bolton has represented Y in a claim for Clinical Negligence against York Teaching Hospital NHS Foundation Trust following the tragic and avoidable death of her baby at 33 weeks gestation. Y lost her baby due to negligent care and advice provided during the antenatal period.

Maternity ward sign

About the case

In early June 2020, Y reported to her GP stating that she thought she was 4-6 weeks pregnant. Her booking appointment was undertaken at the end of June 2020 where she was noted to be a low risk pregnancy.  This was Y’s first pregnancy and she and her family were very excited.  At her early ultrasound scans, Y’s baby was noted to be small for its size, which meant she had to have slightly more frequent and more in-depth ultra sound scans.

Y’s additional scans continued to note that the baby was small but all findings were reported as normal. There was some suspicion that there could be an issue with Y’s placenta. However, she was reassured and provided with advice regarding movements and signs of pre-eclampsia.

Y continued to be followed up.

On the 4 Dec 2020, Y attended York Hospital for a further scan. York had been recording a parameter called the pulsatility index (the pressure) of the umbilical artery. If this pulsatility is weak, that is a sign that not enough blood flow is getting to the baby. York recorded the figure on 4 Dec but failed to recognise the figure indicated that the flow of blood to the baby was low.

Y re-attended on 10 Dec, now 33 weeks pregnant. She had not felt any movement from her baby since the evening before. An ultrasound was performed and unfortunately it was confirmed that Y’s baby had died.

Y’s baby was born shortly after following an induction of labour.

The Claim

Y instructed Tamlin Bolton after receiving an independent report from Leeds NHS Trust who were concerned by York’s approach to record keeping and monitoring. They also stated it was impossible to tell if the baby would have survived.

Following an investigation, Tamlin sent a Letter of Claim to York alleging that York had failed to correctly interpret the pulsatility of the umbilical artery on 4 Dec and had they done so, they would have seen that there was a lack of blood flow to the baby. It was alleged that steroids would have been given or early delivery prompted and the baby would have survived.

In their response, York claimed (quite controversially) that the technical equipment needed to report the pulsatility index was not available to the Trust in 2020 and that this was in line with most Trusts in 2020 .”

Tamlin was aware that Switalskis have other claims where Trusts have been recording the pulsatility index as far back as 2001. Indeed, the guidance from the Royal College of Obstetricians and Gynaecologists about the importance of doing it was published in 2013. Therefore to not have the equipment to do this 7 years later was deemed a serious issue.

Tamlin responded to York Hospital to advise that there was no special software or equipment required, rather all they had to do was look up a reference chart to see if the reported measurement was within the normal range. These reference charts are available free online.  Further, it made no sense for York to record the Pulsatility index number if they couldn’t do anything with it as they had suggested and finally, the Hospital should not have been looking after a small baby if they couldn’t interpret any of the measurements they were taking.

In response to that letter, York then advised they wished to settle the case.

The total damages covered the loss of bringing a pregnancy to completion, the cost of items Y had bought in preparation for her new baby and a significant injury.

It has been a privilege to represent Y, who has been both brave and fearless in holding the Defendant Trust accountable for its catastrophic failures in the face of the Trust’s adamant arguments that no negligence had occurred.

We support many families who have sadly suffered at the hands of hospital Trust failures, in particular failings to undertake investigations that lead to serious injuries and in some circumstances death. If you have been affected by any of the above,  call 0800 138 0458 or email

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Clare has worked in Medical Negligence for over 10 years.  She’s a Solicitor in our Medical Negligence team based in Switalskis’ London office.


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