Chances to save baby were missed
ABABY boy died after maternity staff at Plymouth’s Derriford Hospital repeatedly missed chances to intervene to save his life, an official investigation has found.
Giles Cooper-Hall was just 16 hours old when he died following a catalogue of errors in the maternity care of his mother, Ruth CooperHall. A Healthcare Safety Investigation Branch (HSIB) report into the incident, published this week, has exposed how inexperienced and overstretched staff failed to carry out proper checks, recognise there was an emergency or seek help from senior doctors until it was too late.
One member of staff even pressed the patient buzzer instead of the emergency alarm when they were unable to hear the baby’s heartbeat.
The report revealed how Mrs Cooper-Hall, then aged 37, was not seen face-to-face by a consultant when she went into labour in October last year, despite recommendations made in the interim Ockenden Report published nearly two years beforehand in December 2020.
The HSIB report also suggested
Giles’ death could have been avoided if staff knew about the care plan for his mother’s labour. Instead, vital messages were not passed on, with the investigation finding this was likely to be because the staff responsible were “distracted” by other tasks. The report issued five safety recommendations to University Hospitals Plymouth NHS Trust in a bid to prevent future deaths.
Mrs Cooper-Hall and her wife, Allison Cooper-Hall, 39, said the investigation had highlighted a “delay in recognition of the severity and urgency of the situation”.
They said: “Our utter sadness and despair at losing Giles has been joined by anger and hurt as we now know that human error contributed to his death. We should have come home with our baby – we will grieve for him forever.”
Giles was delivered by forceps and had to be resuscitated for 20 minutes before his heartbeat was heard. He was unable to breathe on his own, suffered blood loss and had brain damage from being starved of oxygen during labour. His death was referred to the coroner and a date for the full inquest is expected to be released shortly.
A spokesperson for University Hospitals Plymouth NHS Trust said: “We would like to extend our gratitude to the investigating team for their support of both the family and the staff involved.
“All the safety recommendations stemming from the investigation will be fully implemented as part of our commitment to foster a culture of learning, development and improvement within the maternity setting.
“Most importantly, we would like to thank the Cooper-Hall’s. We have been honoured to have the opportunity to be involved with the family and maintain an open dialogue whilst the investigation has progressed; explaining how we will develop services reflective of the HSIB findings.
“May we again reiterate our most sincere condolences upon the sad loss of their son, Giles. The pain and distress they have experienced is immeasurable.”