Baby death prompts warning to Princess Alexandra Hospital in Essex
A coroner has raised concerns about maternity care and staff procedures after the death of a three-day-old baby born at Princess Alexandra Hospital in Harlow
Last updated 22nd May 2025
A coroner has warned Princess Alexandra Hospital NHS Foundation Trust that changes must be made after a newborn baby died following delays in medical decisions during labour.
Three-day-old Emmy Russo died from a brain injury caused by lack of oxygen shortly before her birth at Princess Alexandra Hospital on 9 January 2024. She was delivered by emergency caesarean section at 21:30 but was born in a very poor condition.
Assistant coroner Thea Wilson concluded an inquest into Emmy’s death on 7 May 2025 and has now issued a Regulation 28 report to prevent future deaths. She said: “There is a risk that future deaths could occur unless action is taken.”
Emmy’s mother had been booked for an induction at 41 weeks and four days but told the inquest she delayed this after not being fully informed about the risks of continuing the pregnancy. She said she had been encouraged to labour naturally by midwives.
She arrived in labour at the hospital on the morning of 9 January. Her waters broke at 13:45 and meconium was suspected. This was confirmed at 15:10, and a CTG trace was started to monitor the baby. Despite this, no doctor reviewed the situation at that point, although staff agreed one should have.
The coroner said the CTG readings were never normal and showed signs of hypoxia. A doctor’s review was indicated several times throughout the afternoon and evening but either did not happen or was delayed. A final review at around 21:00 led to the decision for an emergency caesarean.
“There were a number of missed opportunities to have delivered Emmy sooner,” said Ms Wilson. “Had a decision been made at or before 19:30, her death would probably have been avoidable.”
Emmy was transferred to Addenbrooke’s Hospital later that night. Although her organs began to recover, scans showed a severe brain injury. She was moved to palliative care and died shortly after being extubated on 12 January 2024.
The inquest concluded that Emmy died as a result of an acute hypoxic brain injury shortly before birth. The medical cause of death was recorded as severe hypoxic ischaemic encephalopathy caused by placental dysfunction.
In her prevention of future deaths report, the coroner raised two main concerns.
First, she said the information currently provided to pregnant women about induction does not meet national guidance. It includes the risks of induction but not the risks of continuing the pregnancy past 41 weeks, meaning patients may not be making fully informed choices.
Second, she raised concerns about the escalation process when there are concerns about labour or abnormal CTG traces. Although the hospital has introduced new tools like “Teach or Treat” and “AID” to guide staff decisions, the coroner said there was limited evidence that midwives fully understand or regularly use them.
The hospital trust has until 14 July 2025 to respond to the report and explain what action it will take to prevent similar deaths in the future.
Sharon McNally, chief nurse and deputy chief executive at The Princess Alexandra Hospital NHS Trust (PAHT), said: “We offer our deepest condolences to baby Emmy’s family on their sad loss.
“We recognise the Coroner’s findings and we sincerely apologise to baby Emmy’s family.
“The safety of women, babies and families when receiving maternity care is our absolute priority and we ensure that learning from any incident is part of our focus on continuous improvement.”