Staff ‘nothing short of shocking’ before baby Kaylan’s death
CORONER: TRAGEDY ‘COULD AND SHOULD HAVE BEEN AVOIDED’
A CORONER says a seven-day-old baby’s death “could and should have been avoided”.
Assistant coroner Laurinder Bower recorded a narrative conclusion after the inquest into Kaylan Coates’ death on the Queen’s Medical Centre’s neonatal ward after a rotational forceps delivery.
The coroner said she was satisfied that neglect probably contributed to his death and that the fact that Miss Coates’ request for a caesarean was not passed on was “nothing short of shocking”.
Mum Hayley Louise Coates’ first child suffered a prolonged slow heart rate and his brain was starved of oxygen during his delivery.
A pathologist told the inquest that Kaylan’s skull was fractured by forceps, leading to a bleed on the brain.
A week later, he contracted a hospital-acquired pseudomonas infection which was likely transmitted by a member of staff or shared equipment. Due to his already weakened condition, the infection – along with the oxygen starvation – caused his death on March 30, 2018.
The coroner said: “He died as a result of overwhelming infection against a background of hypoxic brain injury and birth trauma that occurred due to multiple failings in his care.
“His death was contributed to by repeated serious failings throughout the medical management of his mother’s labour, and missed opportunities to prevent his deterioration during his neonatal care.
“His death could and should have been avoided,” she told the sociallydistanced inquest in Nottingham into his death.
During her findings the coroner asked found that Miss Coates’ labour was not managed appropriately in accordance with local and national guidance, citing multiple failings.
At 6.50pm, there was a failure to escalate to doctors Miss Coates’ request for a caesarean section delivery.
At 8.10pm, the planned medical review failed to properly explore Miss Coates’ wishes with regards her chosen mode of delivery.
If Miss Coates’ wishes had been properly explored, she would have maintained her wish for a caesarean section delivery, and it would have been reasonable to have performed a planned procedure before Kaylan’s condition deteriorated.
“These failures led to a missed opportunity to have delivered Kaylan safely and would probably have avoided his death.”
Emily Rose, a solicitor who specialises in medical negligence and inquests, helped Miss Coates, of Broxtowe, prepare for the inquest.
Speaking on behalf of Miss Coates – who is currently on maternity leave – Miss Rose said: “Kaylan survived for a week before contracting a pseudomonas infection, which, according to the pathologist at the inquest, is what took Kaylan from being a very poorly baby to the end of his life. The coroner said Kaylan was one of three babies on the neonatal intensive care unit who tested positive for the infection, highlighting that infection-prevention methods were not followed as closely as they should have been.
“As she was overdue and in a slow labour, Hayley was a high-risk patient. However, the midwife allocated to Hayley was newly qualified – despite it being a quiet evening on the maternity ward, according to witness statements. In her conclusion, the coroner said that on the night before Kaylan’s birth, there were long periods of time where staff on the ward were socialising and online shopping.
“It wasn’t until five hours after giving birth to Kaylan that Hayley was able to see him, and what she saw will be ingrained in her mind forever – she was broken and in shock at seeing her child laying lifeless in an incubator on a ventilator, wrapped up in a cooling blanket and surrounded by lots of wires.
“For the first few months after Kaylan’s death, Hayley didn’t leave the house.
“The death of her baby boy has affected her mental health and up until the conclusion was delivered by the coroner, Hayley had no idea how her first-born baby had died.
“While the inquest won’t bring Kaylan back, it is hoped that his early, tragic and avoidable death will help prevent other parents from suffering the same devastating loss as Hayley and her family. We are currently working with Hayley and her family and looking into whether or not legal action against the hospital is appropriate.”
Medical director Dr Keith Girling said: “We are deeply sorry that this tragic incident happened and would like to offer our sincerest condolences to Miss Coates and her family. Our learning from this will inform part of the improvements we are making to our maternity services.”