Cause of skull fracture and a bleed on M’s brain
21. On 14 July 2024, Miss J delivered her baby, M, by c-section. Following delivery, a doctor told Miss J her baby had a skull fracture and small bleed on her brain.
22. Miss J told us she believes the Trust caused M’s skull fracture and small bleed on her brain during their c-section delivery.
23. The Trust said a case review conducted in 2018 highted that ping pong fractures develop in two distinct forms, iatrogenic (accidental during delivery) or spontaneous (without cause). The review observed spontaneous fractures where there was no external trauma, cephalopelvic disproportion (where the baby’s head is too large to fit through the mother’s pelvis) or difficult delivery.
24. The Trust said skull fractures are very rare during or immediately after birth and can occur spontaneously. It explained there is an increased risk of a skull fracture if the baby’s delivery is assisted with forceps (a medical instrument used to assist delivery of the baby) or ventouse (a suction cup). The Trust said the risk is also increased if the baby’s head is deeply impacted into the mother’s pelvis, vaginal push up (pushing the baby’s head up into the uterus from the vagina) and/or during a difficult delivery.
25. The Trust said M’s head was not deeply impacted into Miss J’s birth canal and it did not use forceps or a ventouse to assist the delivery of her head. The Trust said the surgical notes highlight M’s head was not engaged into Miss J’s pelvis and was noted to be high on entry to the womb. The Trust described M’s delivery as routine with no complications or difficulties documented. The Trust also said there is no record Miss J had any external stomach trauma prior to her c-section.
26. In the Trust’s final complaint response, it said it could not confirm the cause of M’s skull fracture. The Trust said based on the reasons it gave in its first response, it cannot exclude the fracture occurred spontaneously.
27. We have obtained Miss J’s c-section records from the Trust and obtained clinical advice from our obstetrician clinical adviser. We asked our obstetrician adviser if the Trust’s explanation regarding the skull fracture being spontaneous is a possibility.
28. Our obstetrician adviser explained minor ping pong fractures, like M’s, can be spontaneous or can occur during delivery. This is because a baby’s skull is very soft and flexible.
29. Our obstetrician adviser explained these fractures can also happen from blunt trauma or pressure to the uterine wall (three layers that make up the uterus), while a baby is in the womb. Our obstetrician adviser explained the trauma or pressure to the stomach does not need to be major for this to occur. A slight bump, pressure from the uterine wall, pressure from the mother’s pelvis or ribs, persistent pressure from a baby’s limb or crowded intrauterine conditions (e.g., low amniotic fluid, multiple pregnancy) can cause this.
30. Our obstetrician adviser explained in cases like this spontaneous means there is no obvious trauma, no difficult delivery and no use of forceps, ventouse or an accident. They explained as the records do not suggest M’s delivery was difficult, or that doctors used forceps or a ventouse, it is unlikely the fracture occurred during delivery. They also noted no record of external trauma prior to delivery. This leaves the explanation of the ping pong fracture occurring spontaneously.
31. We recognise from what Miss J has told us, she believes if M’s fracture had occurred in the womb, the Trust would have picked this up during her ultrasound scans. We understand from what Miss J told us she had an increased number of scans because of reduced movements due to her placenta being at the front.
32. We asked our obstetrician adviser if the fracture had occurred in the womb, would it be expected that the Trust should have picked this up in the pregnancy ultrasound scans.
33. Our obstetrician adviser explained pregnancy scans would not pick up minor fractures. The sonographer uses the scan to check the baby’s growth and wellbeing by taking basic measurements of the baby’s head, abdominal wall and femur (upper leg). Our adviser told us a reasonably skilled and qualified sonographer would not be expected to pick up subtle skull fractures, like in this case. Therefore, if the fracture was present during an ultrasound scan the Trust has not breached any duty of care by failing to identify it.
34. Regarding the bleed, the Trust said in its first response the initial CT scan report documented no bleed. The Trust acknowledged Miss J’s copy of this report has a handwritten comment from a doctor stating a neurosurgeon from a children’s hospital (not part of this Trust), reported a very small subdural (collection) bleed, not reported on the scan. The Trust said given this discrepancy, it would request a review of M’s CT images again.
35. The Trust’s records include the CT scan images and the initial CT scan report from 14 July 2024. They also include the review CT scan report, completed by a paediatric radiologist at a children’s hospital that is not part of this Trust (the children’s hospital), on 10 November 2025. Both reports do not document a bleed.
36. We obtained advice from a consultant neuroradiologist about the CT scan images and discrepancy in opinion between the neurosurgeon at the children’s hospital and general consultant radiologist. Our neuroradiologist adviser explained on review of the CT scan images, they do not consider there is a bleed.
37. Given it is the opinion of three consultant radiologists (two of whom specialise in children’s imaging) that there is no bleed between the skull and the brain, on balance we cannot say the Trust caused a bleed.
38. We recognise Miss J also complains the Trust provided her inconsistent information regarding whether M had a bleed on their brain. We will address this part of her complaint separately within our statement. We go into more detail about this from paragraph 51.
39. We understand from what Miss J has told us she wants a clear explanation as to how M’s skull fracture happened. On balance, we cannot say for certain how this happened. We know this will be disappointing for Miss J.
40. We know from our obstetrician advice that skull fractures, like M’s, can happen spontaneously or through delivery. We recognise there is an increased risk during delivery if forceps or a ventouse are used or the baby’s head is deep in the mother’s pelvis or birth canal.
41. Given the records do not evidence these factors were present in Miss J’s case, on balance, we consider there is no evidence to suggest the Trust caused M’s skull fracture. There is no evidence in the records of any external trauma prior to Miss J’s c-section. Therefore, we consider a spontaneous cause to be a reasonable probability. Additionally, based on our consultant neuroradiologist advice we cannot say M had a bleed on their brain.
42. Given this, we do not consider there to be any indications of a failing for this part of her complaint, and we will not be considering this part of her complaint further.
43. We recognise from what Miss J has told us this was an extremely distressing time for her. We do not intend for our decision to underestimate how these events affected her. We hope our decision has provided her with further information to understand how these fractures can occur and reassurance there we have not seen any indications there was a bleed.
Provided inconsistent explanations regarding how M’s skull fracture occurred
44. When we are considering a complaint there will be occasions when we decide there are other reasons why we should not investigate a complaint made to us. This includes that an investigation would not reach a satisfactory conclusion.
45. During our initial call with Miss J, she told us while she was on the ward, a staff member told her a doctor wanted to write in her journal that they did not think M’s skull fracture was spontaneous. She says the Trust then told her in its complaint responses it was spontaneous.
46. In the Trust’s complaint responses, it said during its investigation into the cause of M’s skull fracture, it found no evidence in the records of delivery trauma or external abdominal injury. Therefore, it said it could not rule out the fracture being spontaneous.
47. We understand from what Miss J has told us she feels like the Trust has given her different explanations about how M’s skull fracture happened, which caused her confusion. We recognise her not definitively knowing how causes her distress, which we are sorry to hear.
48. We have reviewed Miss J’s and M’s maternity and postnatal records between 14 and 15 July 2024. We cannot see any evidence in the records that a doctor or staff member recorded they did not believe M’s skull fracture was spontaneous.
49. We must base our findings on objective evidence, such as clinical records and documented communications or statements made at the time. While we acknowledge Miss J’s recollection of events, we cannot say, even on the balance of probabilities, what the staff member told her.
50. For these reasons, we consider it would be difficult for us to reach an evidence based view on whether the Trust gave her inconsistent information about this. Therefore, we have decided not to consider this complaint further and will not be taking further action.
Provided inconsistent information regarding whether M had a bleed on their brain
51. Miss J complains the Trust gave her inconsistent explanations about whether M’s CT scan images showed a bleed on their brain.
52. Miss J says the Trust told her the initial CT scan report said there was no bleed, but a doctor told her a neurosurgeon at the children’s hospital reported there was a small bleed. Miss J asked the doctor to write this on her copy of the CT scan report, which they did.
53. The Trust told us the doctor spoke to the on-call registrar neurosurgeon at the children’s hospital to ensure the family was on the correct care pathway. The Trust said this neurosurgeon reviewed the scan and later called back, advising there was a very small bleed that had not been included in the formal report. The Trust said the doctor wrote this on M’s CT report due to the family’s anxieties at the time.
54. When investigating this complaint, we considered our principles of good administration. Specifically, getting it right, being customer focused and being open and accountable. We also obtained advice from our neuroradiologist adviser.
55. Our neuroradiologist adviser explained neurosurgeons are experienced in reviewing CT scans to facilitate emergency decision making. Our adviser explained neurosurgeons do not receive any formal training in imaging technique or interpretation. This means a radiologist is more experienced and qualified than a neurosurgeon in interpreting CT scan images.
56. Our adviser explained the appearance of a newborn baby’s brain on a CT scan is significantly different than in older children and adults. This is due to a mixture of factors such as the type of haemoglobin (a protein in red blood cells that carries oxygen around the body) in the blood and thinness of the skull).
57. Because of these factors, our adviser told us it is easy to misinterpret the appearances of veins, or a shadow artefact (a false or misleading dark area on a scan) created by the thin skull, as a subdural bleed or collection.
58. From the records, we note a general radiologist (not a specialist in interpreting children’s imaging) completed the initial CT scan report, dated 14 July 2024 and did not report a bleed. Following Miss J’s complaint about the discrepancy between the neurosurgeon’s and general consultant radiologists initial report, the Trust arranged for a review of M’s CT scan images. A paediatric radiologist at a children’s hospital not part of this Trust completed this review on 10 November 2025. A paediatric radiologist is more qualified and experienced in interpreting a baby’s CT scan images than a general radiologist.
59. The review report recorded no obvious surface haemorrhage (escape of blood from a torn blood vessel) and concluded there was a subgaleal collection. Our neuroradiologist adviser explained subgaleal collection means scalp swelling on the outside of the head. Our neuroradiologist adviser explained this report means the paediatric radiologist did not think there is a subdural bleed (blood between sull and surface of the brain) or haemorrhage.
60. We are sorry to hear the conflicting opinions on whether M had a bleed caused Miss J confusion and emotional distress.
61. On balance, we consider at the time the doctor shared the neurosurgeon’s opinion with Miss J, they reasonably believed the information to be accurate.
62. We considered whether the doctor should have taken additional steps to verify the information before sharing it. On balance, we consider it was reasonable for the doctor to rely on the information available at the time. This is because, we know from our neuroradiologist’s advice, neurosurgeons are experienced in reviewing CT scans to determine the need for emergency care. The GMC’s good medical practice emphasises the importance of clinicians working together.
63. For these reasons, we do not consider there is evidence to suggest the doctor had reason to doubt the information the neurosurgeon provided them with.
64. Our principles of good administration say organisations should be open and customer focused. The GMC’s standards on good medical practice emphasises openness and clear communication with patients. We consider the doctor sharing this information with Miss J, rather than withholding it, was in good faith and consistent with these standards.
65. On balance, we do not consider there to be any indications or evidence the doctor acted dishonestly, recklessly or with the intention to mislead Miss J when they shared the information from the neurosurgeon.
66. Based on the initial CT scan report, the review report and our neuroradiologist’s advice, we now know there is no indication that M had a bleed on their brain. We recognise the information the doctor shared from the neurosurgeon is different to this. We are sorry Miss J suffered distress when she was worried about M having a bleed on her brain.
67. On balance we consider the doctor relied on the professional clinical judgement of the neurosurgeon, acted openly by communicating the information they reasonably believed to be correct at the time with Miss J, which is in line with GMC good medical practice and our principles.
68. For these reasons, we do not consider this to be an indication of maladministration or a failing in care. Therefore, we will not be considering this complaint further.
69. We recognise how upsetting it must have been for Miss J during this time. We would like to thank her for her time and effort in bringing this complaint to our attention.