Sara Sutherland and David Illingworth represent family in inquest revealing “gross failures” in maternity care

April 23, 2025

Ida Lock was born at Royal Lancaster Infirmary on 9 November 2019. She died 7 days later due to a hypoxic brain injury sustained in the course of her delivery and subsequent resuscitation. Sara Sutherland, leading David Illingworth, represented the family in the inquest into Ida’s death, which heard five weeks of evidence covering both the care provided to Ida and her mother Sarah, and the Trust’s systems of clinical governance.

The inquest was unusual both in its complexity and in the time taken to reach a conclusion, more than five years after Ida’s death. This was due, in part, to concerns regarding the Trust’s systems of clinical governance. The Coroner determined at the pre-inquest stage that these concerns were sufficient to engage Article 2 of the European Convention on Human Rights, leading to a broadening in the scope of the inquest.

The Coroner, summing up on 21 March 2025, concluded that Ida’s death was contributed to by neglect: there was a “gross failure” by the three midwives attending to Sarah and Ida to deliver Ida urgently when it was apparent she was in distress, as well as a “wholly incompetent failure” by the lead midwife to provide basic neonatal resuscitation for the first three and a half minutes of Ida’s life. These failures led to hypoxic brain damage from which Ida never recovered. In his summing up, the Coroner identified eight separate missed opportunities to alter the clinical course of Ida’s delivery.

Ida’s death in 2019 came after a 2015 inquiry led by Dr Bill Kirkup into serious failings in maternity care at the Trust. Dr Kirkup gave evidence at the inquest that there were echoes of his 2015 report in Ida’s case. The Coroner identified a number of serious failings in the Trust’s systems of clinical governance, including a failure to identify problems with the care provided to Ida and Sarah; failures to escalate and act upon concerns; a delay in reporting Ida’s death externally for over a year; and breaches of the duty of candour in respect of the Trust’s communication with the family.

These problems were further compounded by a position statement, filed by the Trust in 2021 for the purposes of the inquest. Ida’s death had been investigated by the Healthcare Safety Investigation Branch (HSIB), who identified a number of serious failings in care. The Trust informed the family that it accepted HSIB’s findings, but then filed a position statement in which several of HSIB’s findings were disputed, relying on expert reports obtained by the Trust. The Coroner characterised this as a “somewhat surreal situation where the Department of Health, through its arm’s length organisation NHS Resolution, was obtaining expert reports to disagree with the Secretary of State for Health’s independent panel of experts at the HSIB.”

Overall, the Coroner concluded that Ida’s death and the subsequent investigation was “a damning indictment of an ineffective, dysfunctional and callous system that has failed this family at every opportunity presented to it”.

The Coroner also issued a Regulation 28 report to prevent future deaths, addressed to the Secretary of State for Health, the Trust, the Integrated Care Board and NHS England. The report highlighted the “deep-seated and endemic culture within the Trust” that was leading to “denial and a failure to learn”. The Trust’s approach to the inquest was characterised as “one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day.”

The inquest has received national media attention. A BBC InDepth report on Ida’s case concludes with the following:

As for Ida Lock’s parents, the road on which their daughter would have grown up leads directly to Morecambe Bay, and a small patch of sand. This is where they scattered some of her ashes. Now they refer to it as Ida’s beach. When they pass by, with their two other children, they regularly blow her a kiss across the sand.

Their fervent hope is that other couples do not experience a similar fate. But they know that long before them, other families also suffered – and they aren’t confident that more won’t in the future.

“Those families went through what we’re going through now,” says Sarah. “But nothing came of it. You can’t trust that [improvements] are ever going to happen.

“I hope something does change.”

Sara and David were instructed by Anna Mills-Morgan of Mackenzie Jones.