Inquest finds baby died after 'neglect due to a gross failure of care' at Royal Stoke
By Jonathan Sutton - Local Democracy Reporter 7th Nov 2025
By Jonathan Sutton - Local Democracy Reporter 7th Nov 2025
A baby died at Stoke-on-Trent's main hospital as a result of 'neglect due to a gross failure of care'.
A coroner delivered the verdict after Fatima Khan, from Stone, only lived for a matter of hours.
Royal Stoke University Hospital blunders included a heart-rate monitoring machine being switched off for 159 minutes and poor communication between staff – exacerbated by consultants only being on-call from 5pm because it was a weekend.
Now the Royal Stoke has made changes following the tragedy – including on-call weekend consultants now being present during post-5pm ward rounds, improved communication, better training, and new laptops.
Mum Rodaba Iqbal had been sent to the delivery suite after being seen at the maternity assessment unit on June 4, 2023.
She was hooked up to a cardiotocography – known as a CTG – to monitor the unborn baby's heart-rate. But the CTG was switched off at 7.36pm and Rodaba was never monitored again until an epidural at 10.15pm discovered that the baby's heart-rate had dropped.
The Royal Stoke declared an emergency and a decision was made to monitor the situation for 30 minutes. But before the 30-minute deadline it was decided to deliver the baby by a C-section.
Fatima was pronounced dead in the early hours of June 5, 2023.
Coroner Emma Serrano ruled that Fatima died from natural causes. The cause of death was given as a hypoxic ischaemic encephalopathy which is an umbrella term for a brain injury.
She told the inquest: "It was not possible to say what caused the hypoxia without the CTG readings.
"Had the CTG stayed on at 7.36pm things would have been different. So I make the finding that had the CTG monitoring stayed on Fatima would have survived.
"Fatima passed away from natural causes as the hypoxia was caused by something in the body. This was contributed by neglect due to a gross failure of care.
"On the balance of probabilities, if not for the gross failure of care Fatima would have survived."
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