Newborn Leo Lamont died at Monklands Hospital in Airdrie on February 15, 2019. Ellie McCormick passed away at Wishaw General on March 5 that year and Mira-Belle Bosch at the same hospital on July 2, 2021.
A fatal accident inquiry found a series of failures in systems of working and reasonable precautions NHS staff could have taken to prevent all three tragedies.
Sheriff Principal Aisha Anwar KC made 11 recommendations, including the creation of a 'trigger list' to identify and assess early labour symptoms and guidance on when women should attend for clinical assessment.
Leo died two hours after birth. His mum Nadine Rooney - who had a history of preterm delivery - gave birth on her bathroom floor after calling Glasgow's Princess Royal Maternity Hospital to report back pain.
When paramedics arrived, Leo was blue and gasping for breath. He was rushed to University Hospital Monklands, where he died due to perinatal hypoxia, placental abruption, extreme prematurity and a lack of oxygen.
The FAI ruled defects at the maternity assessment unit contributed to Leo's death. It could have been avoided if Nadine had been told to attend after her call. It also found no guidance for midwives to assess preterm labour symptoms.
Ellie died at five hours old at Wishaw General. Her mum Nicola McCormick had reported periods of bleeding and reduced fetal movement.
But an examination found observations were within normal limits.
The day before Ellie's birth, Nicola called midwives to say she had contractions. She was told to take painkillers and call back if she was "not coping" or her waters broke. She phoned three hours later and was told to attend.
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The fetal heart rate was low and she had an emergency ca...