Oliver Thorne, a lawyer specialising in inquests into hospital deaths, has represented the family of Giles Cooper-Hall, who died at Derriford Hospital when he was just 16 hours old.
The inquest highlighted a series of issues, including a failure to follow his mother’s care plan, which could have contributed to Giles’s death.
Other errors included a delay in sending the mother to the delivery suite, and emergencies not being declared when Giles’s heart rate could not be detected.
The coroner concluded that we will never know whether these “missed opportunities” would have changed the outcome”.
She found that the baby died from severe hypoxic ischaemic encephalopathy caused by placental abruption which occurred in absence of continuous CTG (baby heart rate) monitoring.
Commenting after the inquest Oliver said:
“This was an incredibly sad case where basic medical care was not provided. The crux of the case was a failure of the midwives to handover the care plan and to ensure that medical records were checked correctly. The family have had a thorough inquiry into the death of baby Giles and the narrative verdict was welcome.”
Five safety recommendations have been made, which it is hoped will reduce the risk of a similar occurrence in future. These require the health Trust to:
- Support staff to complete a risk assessment, which includes review of the records, at every point of handover of care to enable recognition of a mother’s risk status.
- Ensure that staff are supported, prior to deciding if intermittent auscultation (listening using a hand-held Doppler) is the appropriate method of monitoring, that a risk assessment is undertaken.
- Ensure that intermittent auscultation is undertaken and documented in line with local and national guidance. When staff are not able to fully comply with guidance, they should be supported to request help to ensure there is adequate foetal monitoring in labour.
- Ensure that clinical staff are aware that pink amniotic fluid and or blood-stained amniotic fluid should be recognised and documented to aid planning of further care.
- Ensure that staff recognise when a foetal heart rate cannot be heard or there is a suspected bradycardia that immediate escalation occurs, and an emergency is declared.
The inquest has made national headlines following widespread concerns over the standard of maternity care in the NHS, with the case being reported on by the BBC, ITV, the Mirror, and the Daily Mail.
Oliver said a concerned nation is watching, and that he will continue to closely monitor standards in maternity care in the NHS.
Any families who are affected by similar issues or are looking for a lawyer specialising in inquests into hospital deaths may wish to contact our free legal helpline.
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