Newborn baby died after 999 crew’s blunder Medics used wrong technique in delivery
A NEWBORN baby died from serious brain damage after ambulance staff used an out-of-date technique to deliver him.
West Midlands Ambulance crew were called to the Solihull home of Sarah Robinson, 30, and James Morris, 37, after Sarah began suffering stomach pain 33 weeks into her pregnancy on April 15 this year.
Her partner called an ambulance at 6.14am and it arrived 27 minutes later.
An ambulance that was closer to the couple’s home was not sent because the crew were about to finish their shift.
Jack Robinson-Morris was found to be breached when his mother delivered his legs, body and left arm spontaneously in the back of the ambulance on the way to Heartlands Hospital.
Paramedics pulled over and tried to deliver his head unsuccessfully before continuing the journey to hospital.
But at Heartlands Hospital Jack was rushed to the neonatal unit where he was found to have suffered a severe brain injury caused by a lack of oxygen when his head was trapped during delivery.
Baby Jack died in his mother’s arms on April 18 after she and James decided to turn off their son’s life support.
A subsequent investigation by West Midlands Ambulance Service found the ambulance staff had used an out-of-date technique.
They had not seen the latest guidelines on how to deal with the scenario and the last mandatory ‘maternal emergencies’ training had been five years previously.
Ms Robinson said: “It remains incredibly hard to think about what happened to Jack and it is still hard to believe that he is gone.
“Every day is a real struggle. Our arms ache to hold our little boy again.
“Jack was the most perfect and beautiful little boy who we miss so much.
“It is so difficult not to be angry about what happened, how we feel let down and most importantly how we feel Jack was let down.
“I should be holding my boy in my arms, instead Jack passed away peacefully on my chest. I wouldn’t wish the pain our family is going through on anyone.
“All we can hope for now is that he didn’t die in vain and the ambulance services learns from what happened to him so others don’t have to live with the pain our family is having to endure.”
The couple are now calling on the Ambulance Trust to implement recommendations included in its own serious incident report including all staff undergo training, guidance cards of what to do during obstetric care and all control staff be reminded of the service’s end-of-shift policy.
An inquest held in August identified a range of concerns, including the ‘wrong’ ambulance being dispatched which delayed Jack’s arrival in hospital.
It added staff should not have tried to support Jack when attempting to deliver but let gravity deliver him.
Zoe Smith, expert medical negligence lawyer at Irwin Mitchell, who is representing the family, said: “The findings included in the Ambulance Trust’s own report and the findings of an inquest into Jack’s death are worrying.
“We recognise that the Ambu- lance Service has made several recommendations in its incident report and we urge it to ensure these are implemented as soon as possible to improve patient care for others.”
West Midlands Ambulance Service said it was ‘committed’ to learning from the tragic case.
A spokesman said: “The trust is committed to learning from this tragic case and has already started implementing the seven recommendations that came from the route cause analysis. In particular, the roll-out of further obstetric training will be provided to all frontline operational staff.
“The trust has re-enforced the policy around the sending of crews at the end of their shift so that patients receive the fastest possible response
“The trust has appointed a maternity advisor who is working with the clinical team to further develop learning around this area of treatment.”