A baby who died hours after being born with severe brain damage and multi-organ failure as a result of oxygen deprivation would "likely have survived" had her mother been admitted to hospital hours earlier, a fatal accident inquiry has heard.
Glasgow Sheriff Court heard that there were "major system of care issues" in the lead up to the birth of Ellie McCormick at Wishaw General in March 2019, including the implementation of a Scottish Government maternity pilot scheme in the Lanarkshire region which resulted in her mother Nicola McCormick being switched to a new midwife late in her pregnancy.
The 'Best Start' initiative was geared to improving continuity of care by assigning a single named midwife to each expectant mother for the duration of their pregnancy and labour, but the inquiry heard that the handover process between Ms McCormick's former and new midwife in February 2019 was "non-existent".
As a result, previous issues with vaginal bleeding and reduced foetal movement were not red flagged.
The FAI is investigating the cases of three infants - Mirabelle Bosch, Ellie McCormick, and Leo Lamont - who all died in Lanarkshire in circumstances that the Crown Office has said "give rise to serious public concern".
In the first day of evidence in relation to the McCormick case, the court was told that 20-year-old Nicola McCormick was a first-time mother who lived with her parents in Uddingston.
Due to a BMI in excess of 35, Ms McCormick was classified as obese and placed on the red pathway as a high-risk pregnancy requiring regular reviews by a consultant obstetrician.
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Over the course of her pregnancy she experienced several episodes of bleeding and twice reported reduced or no foetal movement, at 26 and 36 weeks.
She attended maternity triage at Wishaw General on February 3 2019, reporting that the baby had not moved since the previous day.
She was assessed by Catherine Murphy, a retired midwife covering a bank shift, who told the inquiry that the baby's heartbeat was "perfectly normal" but referred Ms McCormick for an ultrasound the next day.
On February 13 2019, Ms McCormick was seen at a Hamilton antenatal clinic by her consultant and met for the first time with her new midwife, Catriona Hand.
In an affidavit, Ms McCormick said that the doctor "did not ask about any bleeding, foetal movements, or any other concerns" and that "nothing was asked of me other than general checks and questions".
She also queried why she had a new midwife "so late in pregnancy" given that her due date was February 26.
Giving evidence, Ms Hand - who had been a hospital-based midwife prior to joining the 'Best Start' community midwifery pilot - conceded that there was no "formal handover" between herself and Ms McCormick's previous midwife, and that issues including bleeding and foetal movements were not clearly highlighted in the BadgerNet IT system used by midwives to review and update patient records.
Asked by Darren Deery, the lawyer representing the McCormick family, whether it was fair to say the handover process was "non-existent", Ms Hand agreed that it was.
Mr Deery told the inquiry that it was "ironic" that the rollout of 'Best Start', an initiative designed to improve continuity of care, had resulted in Ms McCormick's midwife being "changed at 36-38 weeks despite the fact that she was a high-risk red pathway patient with reduced foetal movement and episodes of bleeding".
Ms Hand said it had "seemed the right thing to do at the time", but in retrospect had been a "very hard time" for the midwives involved.
"The whole point of continuity of care is to avoid this exact situation," said Mr Deery.
"Yes," said Ms Hand.
Asked by the lead counsel for the inquiry whether she "would have been aware of these complications" had she read Ms McCormick's notes in full prior to their first meeting, Ms Hand agreed, but added: "It's very difficult in a community setting.
"You have 10 minutes to look through an entire set of notes. In an ideal world, you'd have all the time to go through patients' notes with a fine toothcomb."
She added that the system now uses an "alert" to flag up such clinical history to midwives.
Ms Hand told the inquiry that she did ask Ms McCormick whether she had experienced any problems with her pregnancy, but that Ms McCormick told her it had been "fine".
Following the appointment on February 13 2019, Ms McCormick's consultant was satisfied based on a recent health foetal growth scan to discharge her onto the "green" pathway - meaning her care would be midwife-led instead.
On March 4 2019, Ms McCormick went into labour.
At around 4.30pm that day, she phoned Wishaw General to say that she was experiencing painful contractions at two to three minute intervals but her waters had not yet broken.
She was advised to stay home and have a "hot bath".
Three hours later, she phoned again to say she could no longer cope with the pain as contractions were lasting 60 seconds at a time.
She was admitted to the labour ward at 8.29pm where a midwife assessed that the foetal heartbeat was just 75 beats per minute - well below the 110-160 expected.
Ms McCormick was rushed into theatre for an emergency caesarean, but Ellie was born "floppy" with "no signs of life" shortly before 9pm.
Following resuscitation, she was transferred into the neonatal unit but life support was withdrawn in the early hours of March 5 2019 due to brain damage, multi-organ failure, and very low blood pressure.
The cause of death was hypoxic ischaemic encephalopathy, caused by oxygen deprivation during birth.
Her birthweight was healthy, there was no sign of injury or abnormality, and no "obvious cause of foetal distress" was found during the C-section.
A post-mortem report concluded that "it is likely Ellie would have survived" had her mother been called into hospital at 4.30pm or earlier on March 4.
A Significant Adverse Event Review (SAER) carried out by NHS Lanarkshire in May 2019 found that "major system of care issues" had also complicated Ms McCormick's case.
The inquiry, before Sheriff Principal Aisha Anwar, continues.
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