‘Our baby boy deserved best chance at life’
CORONER RULES MEDICS NOT TO BLAME FOR DEATH BUT SAYS MISTAKES MADE
THE parents of a baby boy who died shortly after being born say they lived ‘every parent’s worst nightmare’ and feel ‘bitterly let down’ by a hospital trust.
Martin and Cassie Smith’s son Franco died soon after his birth, at North Manchester General Hospital in November 2016.
A two-day inquest hearing, held at Manchester coroner’s court, heard that Franco died because he was suffering from congenital pneumonia as a result of an undetected bacterial infection.
Pennine Acute Trust carried out an internal investigation following Franco’s death and found that the results of a foetal heart monitor (CTG) were interpreted inaccurately on a number of occasions during Mrs Smith’s labour.
The results were interpreted as being ‘reassuring’ or ‘suspicious,’ when, as the trust investigation later discovered, they should have been classed as abnormal.
A coroner has concluded however, that even if the results had been interpreted correctly, Franco would not have survived because of the infection.
The inquest heard that Franco’s mother Cassie was admitted to the labour ward at around 8.30pm on November 10, 2016.
Three hours later, the midwife in charge of her care asked for a medical review after finding that Mrs Smith’s heart rate had increased.
Mrs Smith was assessed five times between 11.30pm and 3.40am, with the ‘concerned’ midwife asking for a second medical review at 2.15am, but the CTG results were misinterpreted as being ‘reassuring’ or ‘suspicious.’
An ‘abnormal’ verdict would have led to a foetal blood test being carried out, but the coroner concluded that at this stage, the results of a test would have come back normal, and labour would have been allowed to proceed naturally.
At 4am, Mrs Smith’s midwife asked for another medical review, but the two doctors on duty could not attend as they were both in surgery at the time.
At 5am, another midwife noted that Franco’s heart rate had been decelerating for 85 minutes, and was so concerned that she went into the operating room to ask for a doctor to come and see Mrs Smith.
When a doctor saw Mrs Smith at 5.10am, he planned for a foetal blood test to be given, unless Mrs Smith delivered imminently.
Franco was then delivered by midwives at 5.35am and let out a cry, but was ‘in a poor condition and floppy.’
When he did not respond to being rubbed by a midwife, he was given inflation breaths, using air, to try to inflate his lungs.
On the first day of the hearing, Franco’s father Martin and aunt Michelle Smith gave evidence about the moments following his birth.
Ms Smith, who was her sister-inlaw’s birthing partner, said: “I wasn’t concerned when I saw the cord around his neck because my friend’s son was born like that.
“It was when he was at the resuscitaire and I could see how vigorously she (the midwife) was rubbing him, that’s when I started to get worried.”
When paediatricians arrived in the delivery room four minutes after Franco’s birth, they found that he did not have a heart beat and did not respond to resuscitation.
Coroner Mr Anthony Mazzag concluded that had Franco been delivered before midnight, there was a possibility that he might have been in a better condition, but there would have been no evidence at that time to suggest that delivery should have taken place then. The hearing heard that maternity services at the hospital were rated inadequate by the Care Quality Commission some months before Franco’s death in 2016.
They were subsequently rated as good in a 2018 inspection.
Dr Caroline Rice, clinical director for obstetrics and gynaecology, was the lead investigator of the internal Pennine Acute Trust investigation into Franco’s death.
The doctor told the hearing that a number of improvements have been made since 2016.
Speaking after the inquest, Franco’s parents said: “The past three years have been horrendous. We feel bitterly let down by the Trust and have waited a very long time to get answers into what happened to our baby boy.
“We find it very hard to forgive the mistakes that were made and although the coroner has decided that a paediatrician being present would not have made a difference to Franco, we believe that he deserved that chance.”
We find it very hard to forgive the mistakes that were made Franco’s parents Cassie and Martin Smith