Death of baby Ethan was ‘avoidable’ rules coroner
HE SHOULD HAVE HAD C-SECTION HOURS EARLIER AT HOSPITAL
MISSED opportunities led to the avoidable death of baby Ethan Blackwell, a coroner has concluded, with his parents joining calls for a national maternity inquiry.
Coroner Sabyta Kaushal concluded in Derby yesterday that Ethan would have survived if he had been delivered by caesarian-section seven hours earlier.
He was eventually born at Royal Derby Hospital at 5.35am on May 21, 2021, but died in his mother Jodie’s arms 32 hours later at 9.12pm on May 22.
His parents, Jodie and Ben Blackwell, 23 and 31, from Littleover, had waited three years for an inquest’s conclusion into their son’s death.
Following a three-day hearing, Miss Kaushal found that while there were numerous missed opportunities, she felt this did not amount to neglect, detailing there was “no evidence of gross failure to provide basic medical care”.
She said: “There was a missed opportunity to deliver Ethan at that time [5.35am]. If delivery had taken place at that time, or shortly after, then he would have survived.”
This is the second inquest into a baby death at Royal Derby Hospital in as many months with baby Zachary Taylor-Smith having been found last month to have died after 14 hours of life due to “gross failings” and “neglect” linked to antibiotics in November 2022 – with an accompanying prevention of future deaths report also issued.
Baby Zachary’s parents, Tim and Hannah Taylor-Smith joined Ben and Jodie for the inquest conclusion to offer moral support.
Miss Kaushal said that concerns were not escalated and that equipment dedicated to monitoring Ethan’s heart rate provided “false reassurances” to clinicians.
Her findings that there was not a failure to provide basic medical care hinged on the constant provision of one-to-one care by hospital staff, including two midwives throughout Jodie’s labour.
Miss Kaushal documented a lack of involvement of the parents in the decision-making process with no evidence that they provided informed consent in relation to caesarean section plans being scrapped twice at 3.28am and 5.45am on the day of Ethan’s birth. She found that there was no documentation to show the reasoning for the c-section plans being reversed, which had followed two bradycardia – significant and sustained drops in Ethan’s heart rate.
This was “not documented nor explained”, she said. “It is accepted that Jodie and Ben were not involved in the reversal decision. There is no evidence of informed consent.”
Miss Kaushal also found that Jodie’s personal request for a caesarean section was “not taken into account”.
During the hearings, clinicians said they had not been aware of this request, stressing that they were not denying the request had been made but that they had no “recollection” of it.
Miss Kaushal did not find sufficient evidence to write a prevention of future deaths report after gaining assurances from the trust during the hearings.
Speaking after the conclusion, Jodie said: “This inquest has come after an agonising three-year wait and is just six weeks before the anniversary of our son Ethan’s death.
“We have waited a long time for answers but we are satisfied that the inquest has highlighted the areas where Ethan was failed and we as parents were ignored.
“Ethan was our firstborn son who we couldn’t wait to bring home. He should have never been an opportunity for lessons learnt or a case study in order to make improvements.
“What our baby went through should never have happened. We know he could and should have survived had he been given a c-section by 5.35am or as soon as possible thereafter. We would have had an almost three-year-old healthy little boy playing at home with his little sister.
“We should have been able to bring our beautiful baby boy home where we spent months making everything perfect for him. No apology will ever be enough. We miss him every single day and there will always be a huge hole in our family.
“Whilst we acknowledge Royal Derby’s response and apology we have been left with little trust in medical professionals.”
She said that handling the birth of their daughter Amelia, one, brought back difficult memories, leaving them “crippled” with trauma and in need of therapy.
Jodie said: “We sincerely hope this inquest will help share lessons that will stop mothers and babies dying in this way and begin to restore trust in our maternity service, not just here in Derby but across the country. “We believe there should be a national inquiry into the country’s maternity service. Babies are losing their lives too often and it is something that should be looked at closer.” Garry Marsh, executive chief nurse for the University Hospitals of Derby and Burton NHS Foundation Trust, said: “We are profoundly and deeply sorry for the tragic loss of Ethan and for the continued heartbreak that we know the shortcomings in his care have caused.
“We fully accept that we missed opportunities to deliver Ethan sooner, and we have been determined to make changes in the years since his tragic death in 2021 to make our care safer, particularly around measuring a baby’s heartbeat during labour and how we involve families in decisions about their care.
“We have new heart rate monitoring equipment which tracks oxygen levels and is checked daily, and our staff training rates in this specialist area are now above the national standard with support from dedicated midwifery and doctor leads.
“Our clinical guidelines are up to date with national best practices, and we have changed our escalation, handover and documentation practices so that they support safer and more coordinated care and better involve families in decisions.
“Whilst we know these changes cannot possibly impact on the grief caused to Ethan’s family, we remain absolutely committed to continuing these improvements so that we provide safer care for every parent and baby at our hospitals.”
A key focus of the inquiry was the crucial two hours and 17 minutes between Ethan’s two bradycardia at 3.28am and 5.45am on May 21.
This is a key period in which intervention could and should have led to either a category one or category two c-section respectively, with category one potentially seeing Ethan born within the next 15 to 30 minutes – depending on theatre availability – and category two within 75 minutes, the inquest heard.
The inquest was told how a mother in labour experiencing two bradycardia episodes was “very unusual”.
It also heard that “false assurances” had been given for the apparent perfect health of the baby due to wrongly assumed infallible fetal scalp electrode (FSE) attached to Ethan’s head to accurately monitor his heart rate.
The trust maintained that 5.35am to 6am was the last time at which Ethan should have been born and survived to live healthily.
A recurring issue throughout all three days of hearings is the final hour and half of labour, from 11am on May 21 during which the cardiotocograph machine (CTG) tracking the heart rates of mother and baby are said to have been “uninterpretable”.
There were numerous other periods in which concerns over the CTG were discussed with staff detailing it had become uninterpretable, with senior clinicians saying this ought to have been escalated – but it was not.
Senior staff, including Dr Tirlapur and Kara Dent, clinical director of obstetrics, said that if midwives had persisted in raising concerns over the interpretation of Ethan’s heart rate then they would have expected further action to be taken immediately to rectify that.
However, midwives Danielle Baily and Hannah Purdy did raise these concerns to senior staff and the situation was not acted on, with staff “falsely reassured” by the – at the time – infallible scalp electrode attached to Ethan’s head.
We hope this inquest will help share lessons that will stop mothers and babies dying in this way.
Jodie Blackwell