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Gross neglect led to death of baby at St Mary’s Hospital

THE ENTIRELY preventable death of a baby at St Mary’s Hospital has been branded “gross systemic neglect” by the Isle of Wight coroner. A string of bad decisions and failings during the mother’s labour led to Elliot Williams’s death, one that could and should have been prevented, coroner Caroline Sumeray said. Elliot, son of Chelsea Mouland and Nicholas Williams, of Castle Street, East Cowes, suffered perinatal hypoxic-ischemic encephalopathy – a lack of oxygen to the brain – after delays in his delivery while his heart rate fluctuated to dangerously low levels.

Miss Mouland was induced at 38 weeks because the baby was small for his gestational age – he had stopped growing or his growth had significantly slowed. This, combined with the fact she was induced, made the labour high risk and should have meant staff were especially vigilant. Cardiotocography (CTG), a way of recording foetal heart rate, was used and showed the heart rate dropping.

Midwife Diane Weedon, tasked with the delivery, was criticised by the coroner for not calling for help earlier. Giving evidence at the inquest, Mrs Weedon said she became fixated on helping Miss Mouland with pain management and she didn’t fully appreciate the gravity of the baby’s situation. A Fresh Eyes Review protocol, when another member of the team is supposed to look over the CTG to make sure everything is progressing normally, was not followed, so the severely fluctuating heart rate was not picked up.

When Mrs Weedon finally did call for help, registrar Dr Tin Tin Htwe did not act quickly enough, the coroner said. At this point the baby’s heart rate was pathological and the baby should have been delivered using instruments straight away. However, Dr Htwe did not act and the baby was born naturally around half an hour later, showing no signs of life.

The baby was resuscitated and Dr Mike Hall, a consultant neonatologist, who was called over from Princess Anne Hospital in Southampton, assessed the child as having suffered severe brain damage from lack of oxygen, with long-term damage, if he survived at all. The new parents made the heartbreaking decision it was in the best interests of their son to discontinue care and let him go. The baby was left in his parents’ arms for just under an hour before he died, on December 22, 2015.

Expert witness for the inquest, consultant obstetrician Tracey Johnston, said the death would have been avoided if decisions were made and actions were taken more quickly, and the baby was delivered more swiftly. Mrs Weedon and Dr Htwe were criticised by the coroner and were told to refer themselves to their governing bodies. Both have received extensive retraining since the incident and apologised for the mistakes they made.

Responding to the coroner’s findings, Dr Barbara Stuttle, chief nurse at Isle of Wight NHS Trust, said: “This was a serious incident which we are very sorry about and we have expressed our deepest sympathies and apologised to Elliot’s family. “The trust co-operated fully with the coroner to ensure the full facts were made known. We will be implementing all the recommendations made by the coroner.

“Since this tragic event we have changed and improved practice over the last year and we are committed to continuing to learn to ensure services are safe for patients.

“We believe that the changes we have made to practice since then ensure that babies and mothers are as safe as possible in the maternity unit at St Mary’s.”

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