The death of a baby seven weeks after she was delivered at Queen's Hospital with "catastrophic" injuries was contributed to by "excessive" pulling using forceps, a coroner has concluded.
Nadia Persaud, area coroner for east London, shared her findings with the family of Ada Rose during a conclusions outcome at East London Coroner's Court on January 26 to mark the end of an inquest into her death.
Ada, previously Ada Golden, was born at Queen's Hospital on October 13 after her mother Brooke Golden had been induced at 38 weeks.
But just weeks later, she died having suffered “catastrophic” injuries during her delivery.
Her parents say Ada was "badly let down", with Ms Persaud finding her tragic death was entirely avoidable if doctors had acted differently.
During the inquest, the coroner heard evidence that "regular antenatal reviews and obstetric-led antenatal care" took place during the pregnancy, in which Ada was "progressing well".
NHS trust's response: Queen's Hospital admits care failure over baby's death
The court heard that Brooke developed gestational diabetes at around 32 weeks during the pregnancy, and Ada was measuring up to be a large baby.
According to Ms Persaud, Ada's abdominal circumference and estimated foetal weight "should have resulted in discussions about the risk of shoulder dystocia", though evidence revealed "this was not done".
It was found that the options for delivery were not well made clear to Brooke, particularly surrounding her right to choose a caesarean section and the risks associated with each mode of delivery.
The first stage of labour did not raise concerns, the court heard, with Ada's heart rate monitored as "initially good and reassuring".
After no progress was made with dilation, Brooke was transferred to theatre and an epidural was carried out.
Dr Irene Njoku was one of two doctors present during the course of the labour and delivery, and was "sure" that Ada was not in the correct birthing position and required rotating to the OA position (head down and facing mum's spine).
Ms Persaud found that attempts were made to rotate Ada from the ROT position (the back of her head was facing Brooke's right hip) but were "unsuccessful", with vaginal examinations carried out at several times to determine her position.
A consultant was called to take over "in good practice" and "in accordance with guidance", and carried out another vaginal examination.
During efforts to deliver Ada, the court heard a ventouse "kiwi" cup (a piece of suction equipment) was used by Dr Ebrahim Foroghi and was successful in rotating the baby.
One "full pull" was carried out but after a partial second pull, the cup popped off and this method was abandoned.
Ms Persaud also shared her findings relating to the use of forceps during the attempted instrumental delivery.
A first "pull" using the forceps was conducted by Dr Foroghi but resulted in "minimal descent" of Ada, the inquest was told.
This was followed by a second "pull" by Dr Njoku which also saw little progress.
The court heard how after this second "pull", Dr Njoku concluded she "would not be able to deliver Ada with forceps" and stopped to seek a second opinion.
Ms Persaud found "no reliable evidence" suggesting that a vaginal examination was conducted after the use of the forceps to determine the position of Ada.
A third pull was then carried out by Dr Foroghi, which again saw no descent and Brooke was again "pulled down the bed".
However the court heard how at this time Ada's heart rate, which had up until this point remained reassuring, increased and there was a "loss of variability" on the cardiotocograph, which measures the baby's heartbeat.
Ms Persaud was clear in her findings that this third pull "was not in accordance with the applicable guidance" and that there "should not have been any further pulls after the second pull of the forceps".
During these instrumental delivery attempts, Ms Persaud found that "communication in theatre was poor" with no explanation to the midwife, scribe or parents of the actions being taken.
The court heard that delivery modes were only discussed with Brooke after she had been pushing for more than an hour.
Brooke previously gave a statement to Ms Persaud, in which the coroner revealed the mother recalled "asking whether they could just do a caesarean section" as opposed to attempting an assisted delivery.
Alongside this, Ms Persaud heard that Brooke "does not recall being told of the risk to the baby of an instrumental delivery", lacking time to read a pre-written consent form and having placed her trust in the doctors.
When Ada was delivered via emergency caesarean section after doctors abandoned attempts at an assisted delivery, she was "born in a very poor condition".
Ms Persaud described how the baby was not breathing "spontaneously" and was not "moving her limbs" as expected, with it being "immediately obvious that Ada had suffered".
She had a “severe cervical cord injury” (damage to her spine), “occipital diastasis” (a skull injury) and “cerebellar vermis displacement” (brain damage).
Ada was transferred to Homerton Hospital's neonatal intensive care unit where the extent of the injuries "was noted to be very marked", with clear concern from the neonatal team.
Ms Persaud stressed that between the team of "experienced" neonatal professionals, they were only aware of "one other similar case" across their careers.
Ada died just seven weeks later on November 30, still in hospital.
Ms Persaud said that Ada's "catastrophic and irreversible" injuries were caused by the use of instruments and likely excessive traction during forcep delivery attempts.
She told the court: "The extent of damage seen to the cervical spinal cord together with the force does suggest a high level of pressure applied to the occipital bone.
"The use of the instruments and excess traction contributed to Ada's death."
Ms Persaud called Ada's death "preventable", had the full details of risks associated with each delivery mode been properly explained to Brooke in ample time ahead of her labour.
She said: "I find that good practice required a discussion about the various modes of delivery and the risks associated with those.
"This would have given Ms Golden more time to consider the risks and to make a fully informed decision.
"Consenting during the second stage of labour was sub optimal. She (Brooke) was clearly exhausted by this time. She had been actively pushing for almost an hour and a half, and did not have time to read the consent form.
"Ms Golden would not have heard and digested all of the risks of an instrumental delivery.
"Had she appreciated fully the risk of an instrumental delivery to the baby, she would have clearly requested a caesarean section.
"She had the right to know about the risks to herself and her baby. She did not receive this."
Dr Njoku said that she "believed she would have mentioned the risk to the baby" based on information contained in the consent form, and does not recall Brooke saying she did not want an instrumental delivery.
Ms Persaud told the court: "Dr Foroghi did not write contemporaneous notes of this challenging delivery. Being busy in my view is not an excuse.
"This case demanded Dr Foroghi's attention, reflection and his diligence during this event.
"If guidance is to be deviated from, there should be a good reason for that deviation. I did not hear any good reason in this case."
Brooke attended with her partner and Ada's father, Connor Rose, virtually.
They told the Recorder: "Ada was badly let down. Her death was entirely preventable.
"We miss our baby girl every single minute. Although the inquest is over, this is not over for us.
"We are dealing with a loss that will last a lifetime. Our family will always have a very important person missing. Ada should be here with us. We will speak her name forever."
The case has also been referred to the General Medical Council (GMC), with Ms Persaud requesting details from Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) - which runs Queen's - to share details of where Dr Foroghi is employed so she can inform the medical director of her findings.
It is understood he is no longer in the employment of BHRUT.
Brooke and Connor's lawyer, Samantha Critchley of Fieldfisher, confirmed a negligence claim will continue to be investigated, with a decision from the GMC into Dr Foroghi's fitness to practice not yet received.
She said: "The coroner was critical of the lack of informed consent finding that if Brooke had received proper counselling, either antenatally or during delivery, that she would have had an earlier caesarean section and Ada would have been alive.
"This was a completely avoidable death. Time and time again we hear how women are denied an informed choice over how their babies are delivered, with clinicians talking of the risks of caesarean and none of the risks of a complicated instrumental delivery.
"I can only reiterate the words of the coroner that Brooke and Connor have been incredible throughout this process. This type of tragedy should simply not happen in this country in 2026."
BHRUT has admitted "the fact" that the care they provided was "not up to the standard it should have been".
Evidence heard by Ms Persaud from the trust states that organisational changes have been made in the wake of Ada's death, including having a second midwife for births requiring additional support, and more robust training given to maternity staff.
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