The Calderdale Royal Hospital maternity unit missed four opportunities to save the life of a baby boy, a coroner has said.
Gino Asquith was born “without showing any signs of life” after his mother Sarah Ellis had been left for six hours on busy maternity wards, an inquest heard.
Coroner Oliver Langstaff listed the chances doctors and midwives had failed to to act upon on when Ms Ellis, 28, was taken to the Calderdale Maternity Centre (MAC) at Calderdale Hospital, Halifax, at 7.30pm on Saturday November 8, 2014.
Speaking to Ms Ellis and her partner, Adam Asquith, 32, as he delivered a verdict of death by misadventure at Bradford Coroner’s Court, Mr Langstaff said: “At the very least the delays in Gino being delivered made the chance of him being born alive significantly reduced.
“Gino spent five and three quarter hours at the hospital but it took only 12 minutes after the decision was made, to perform an emergency caesarean section.”
He said Miss Ellis should have been assessed on admittance to MAC and then again when she was later transferred to the labour ward.
Doctors then failed to perform a caesarean section when they realised the baby was suffering with a life-threatening infection in utero.
Doctors also failed at another opportunity to perform a C-section an hour later when the baby was showing problems with its heart.
Ms Ellis’s ordeal began when she went into labour on 7 November 2014 and attended Calderdale Hospital where she was told there was no bed for her and that she needed to go to Huddersfield Birthing Centre.
After a four-hour wait at the Birthing Centre she was sent home on 8 November as her labour was not in an advanced stage.
Later that day she could no longer feel her baby moving and attended Calderdale Hospital, where she was admitted to the Maternity Assessment Unit.
Over the next six hours, the couple were assessed by six midwives, a registrar and senior house officer, and signs of distress were picked up - both mum and baby had abnormal heartbeats and there was the presence of meconium - but none of this information was acted on appropriately.
Ms Ellis was attached to a machine with a button in her hand. She was told to press the button each time the baby moved. But crucially, in the six hours she was there, she didn’t press the button once.
Yet none of these signs set alarm bells ringing, with the seriousness of the situation failing to be passed on.
The fact that Ms Ellis did not feel any movement was not mentioned in her notes. A report showed this information had “slid off the radar”.
The inquest heard midwives and consultants had described the ward as “exceptionally busy”.
Midwives had not passed information on to consultants, as they had been busy.
At one point a frantic midwife had been pacing the corridors trying to find a doctor, but could not find a doctor free, the court heard.
Consultant Obstetritian Mrs Kalvinder Bhabra, who co-wrote a Serious-Untoward-Incident (SUI) report into the tragedy said: “Doctors were busy and that carried on throughout, and sometimes it’s better to get a flea in your ear, and if you don’t ask, you don’t get. Yes, they know you are busy, but they don’t know how busy.”
Ms Ellis wasn’t admitted to the adjoining maternity ward until 11.30pm.
And tragically, by the time Gino was delivered by caesarean section at 2.34am, he was in a very poor condition and was resuscitated twice.
Gino was placed on life support, but tragically Ms Ellis and Mr Asquith were advised to withdraw treatment.
Gino died three days later on 12 November due to severe oxygen deprivation shortly before being delivered.
The pair were so devastated by their ordeal they sought legal advice and pursued a civil action against the hospital.
Ahead of the inquest, the NHS Trust admitted liability for Gino’s death in the civil case after an internal investigation found Ms Ellis’s condition was not escalated to the obstetric team, communication was not clear between staff, that there were delays transferring Ms Ellis to a delivery room and that she was not correctly monitored at the hospital.
Emily Whisker, an expert medical negligence lawyer at Irwin Mitchell representing the family said: “This is a tragic case of the death of a baby, which could have been prevented.
“Sarah and Adam have had a distressing time over the last 18 months and they have been desperate to understand the problems that occurred at the hospital during Gino’s birth.
“It was extremely difficult for them to listen to the evidence given during the inquest but they are grateful to the coroner for conducting such a thorough enquiry and relieved that the Calderdale & Huddersfield NHS Foundation Trust has now admitted liability for Gino’s tragic death.
“Sadly, nothing can be done to change what happened in this case, but Adam and Sarah are hopeful that this terrible experience will lead to improvements in maternity care at the hospital so other families do not endure the heartbreak they have.”
Speaking after the hearing, Ms Ellis, holding hands with Mr Asquith, said: “Words cannot explain what we have been through in losing our first child together in this terrible way.
“It is hard to accept that the delays we faced and the failure to pick up signs that Gino was in distress led to his death.
“The investigation in Gino’s death and the care we received from the Trust found a number of failures and we hope that these issues will be corrected so other people do not have to endure what we went through in November 2014.
“The ordeal we have been through has been completely devastating and we are still trying to come to terms with what happened to our family. We can only hope that by speaking out we will ensure lessons are learned and that mothers and their babies are in the best possible hands when they are at their most vulnerable.”
The Coroner did not make any recommendations to the hospital after hearing a report had already put in place several changes, such as adding an extra midwife, putting all patients together in one room and introducing advanced training.