We should have gone home with our baby... newborn died after catalogue of mistakes
A NEWBORN boy died after maternity staff missed a string of chances to save him, an inquiry has found.
The Healthcare Safety Investigation Branch (HSIB) said staff failed to carry out 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’s buzzer instead of the emergency alarm when they were unable to hear the baby’s heartbeat.
The failures meant Giles CooperHall died at just 16 hours old. His mum Ruth and her wife Allison were told by a consultant neonatologist four days afterwards: “You should have come home with your baby.”
Ruth, who gave birth on October 28, said: “Those words will never leave us. Grief will always be a part of our lives now – it’s all the love you want to give to your baby but cannot.”
Six weeks ago the independent Ockenden Report into more than 1,800 cases revealed serious failings in the maternity care at Shrewsbury and Telford Hospital NHS Trust.The HSIB found similar issues at University Hospitals Plymouth NHS Trust, which manages Derriford Hospital where Giles was born.
The problems began when Ruth, then 37, told staff her baby wasn’t moving as much as normal when she was 41 weeks pregnant. She was discharged and reassured the team was “not concerned at all”. A telltale reduction in her bump’s growth was only noticed when Ruth went in for an induction five days later.
A senior doctor looked at her notes and advised the baby’s heartbeat should be continuously monitored. This was not done. And when she went into labour she was not seen by a consultant, as recommended in the interim Ockenden Report in 2020. Staff also failed to recognise the significance of blood loss, which was a sign of damage to the placenta, and did not act as if there was an emergency when they struggled to find Giles’s heartbeat.
It had been below the minimum level for 21 minutes before any senior staff were called. After they arrived, he had to be resuscitated for 20 minutes. He was unable to breathe on his own and had blood loss and brain damage from being starved of oxygen.
His parents, who have a two-yearold son, were with him when he died at 8.30pm.An inquest will be held. The HSIB issued five safety recommendations. The trust said: “They will all be fully implemented as part of our commitment to foster a culture of learning, development and improvement.” It also offered its condolences.