Coroner finds missed rare umbilical cord defect caused newborn's death
A coroner concluded that a rare velamentous cord insertion was not identified during pregnancy, leading to severe bleeding and the death of newborn Sage shortly after birth.
Coroner Ian Telford determined that a rare velamentous cord insertion, which left umbilical vessels unprotected, was missed on several prenatal scans, resulting in a torn umbilical vein and severe hemorrhage at birth. The mother’s labour progressed normally until the infant’s heart rate fell, prompting an emergency caesarean that delivered the baby in critical condition. Despite immediate resuscitation, the newborn’s condition deteriorated and active treatment was withdrawn, with death recorded two days later.
Pathology confirmed significant blood loss and oxygen deprivation. The review found that earlier ultrasounds showed signs of vasa praevia that were not acted upon, and that the risks were never discussed with the mother. New care pathways and updated guidelines have been introduced to improve detection and management of such cases.
Why it matters
It shows how missed prenatal diagnoses can lead to fatal outcomes and underscores the need for better screening protocols.
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