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Baby death doctor cleared of misconduct.

A consultant gynaecologist doctor whose error of judgment caused a baby to be decapitated during birth has been cleared of misconduct and can return to work.

Dr Vaishnavy Vilvanathan Laxman wrongly proceeded with a regular delivery with a 30-year-old, first-time mother who was 25 weeks pregnant, at the NHS Maternity Unit at Ninewells Hospital, Dundee, in March 2014.

The Medical Practitioners Tribunal Service (MTPS) panel said "the only appropriate course" was a caesarean section as the baby - known as baby B - was in the breech position, with a prolapsed cord and low heart rate, and the mother's cervix was less than 4cm dilated.

The baby's head became trapped during the birth and various techniques were tried to free it, but during this his "head became detached from his body".

The panel said that by this time the baby has already died but the tribunal cleared Dr Laxman of serious misconduct and said her fitness to practise was not impaired.

It ruled the decision to proceed with a natural birth was "negligent and fell below the standards ordinarily to be expected" but did not amount to serious misconduct.

In its written ruling, the panel said: "The failing which the tribunal has found proved was not sustained, persistent or repeated, but rather a single error of judgment made in very difficult circumstances.

"The tribunal was satisfied that throughout the attempted delivery of baby B, Dr Vilvanathan Laxman believed that she was acting in both patient A's and baby B's best interests, and that she genuinely believed that proceeding with a vaginal delivery was the optimum course to take in the circumstances which existed at the time."

The panel added: "The tribunal is satisfied that Dr Vilvanathan Laxman has expressed genuine and appropriate remorse for what happened, and she candidly accepted responsibility as the consultant in charge in theatre that day.

"Further, at no point has Dr Vilvanathan Laxman sought to blame others for what happened or to minimise her actions."

It was ruled Dr Laxman should not receive a formal warning over the case and an interim order on her medical registration has now been revoked.

The report said: "In all the circumstances, the tribunal has concluded that Dr Vilvanathan Laxman's conduct did not fall so far short of the standards reasonably to be expected of a doctor as to amount to serious misconduct.

"In respect of patient safety, the tribunal was satisfied that Dr Vilvanathan Laxman does not currently present a risk to patients. Dr Vilvanathan Laxman's wrong decision related to an isolated, single incident in an otherwise unblemished career."

The panel concluded: "Nothing in this determination should detract from the fact that on March 16 2014 Dr Vilvanathan Laxman made a significant error of judgement which had serious consequences and a profound impact upon patient A and for which Dr Vilvanathan Laxman bears a heavy responsibility."

At  an earlier hearing, Patient A told the tribunal she had previously been informed that the baby would be delivered by caesarean section “if anything happened”, because her baby was in breech.

She said: “The only pain relief I was given was a spray on my tongue. I was told it was meant to loosen my cervix but I was not given gas and air and was in pain. I had the doctors putting their hands inside me and I had them pushing on my stomach and then pulling me down.

“I tried to get off the bed but they pulled me back three times and just said they had to get the baby out. They twice tried to cut my cervix and nobody told me they were going to do it.

“There was no anaesthetic. I said to them ‘it doesn’t feel right, stop it, what’s going on, I don’t want to do it’ but nobody responded to me in any way.

“Afterwards, I was in a cubicle with a curtain around me and the sister came over to me and told me my son had passed away”.

 

 

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