Baby boy died in mum’s arms after being starved of oxygen while ‘midwives joked about how many Haribo they’d eaten’
A BABY died after being starved of oxygen during birth while midwives joked about how many sweets they’d eaten and how much money they earned, an inquest heard.
Theo Bradley had to be resuscitated after there were delays in his care at King’s Mill Hospital in Sutton-in-Ashfield, Notts., in September last year.
Mum Amelia Bradley, 26, said she called for help in agony several times but heard maternity staff chatting – including one saying: “I can’t believe how many Haribo’s I’ve had tonight.”
An inquest heard numerous midwives were sat around the desk while Amelia should have been assessed within 15 minutes of arriving at hospital.
When it was recognised she had not been seen to, one midwife admitted making a comment about a colleague earning more money than her due to working a bank shift.
It was nearly 40 minutes before Amelia and Theo were finally assessed, despite being the only patient in triage and Amelia bleeding.
Theo was found to have a slow heartrate and a decision was made to deliver by category one Cesarean – meaning there is an immediate threat to the life of mum or baby.
After he was born, resuscitation equipment on the unit was found to be missing and Theo was transferred to a specialist neonatal unit for treatment.
To this day, I still wake up and hope it’s all been a nightmare and then it hits me and I’m completely floored by the grief
Amelia Bradley
However, his condition continued to deteriorate and he died the following day in his parents’ arms, surrounded by his family.
A post-mortem examination found he had died after suffering a serious brain injury caused by a lack of oxygen.
An inquest at Nottingham Coroner’s Court reached a narrative conclusion this week.
Nottinghamshire assistant coroner, Elizabeth Didcock, found neglect had contributed to Theo’s death.
She found that if Theo had been delivered earlier, on balance, he would have survived.
Grieving parents Amelia and her partner Luke Sherwood, 26, of Kirkby-in-Ashfield, Notts., are now calling for lessons to be learned following the tragedy.
Amelia, who has applied to start a midwifery degree starting in September, said: “Following Theo’s death, Luke and I discussed how we wouldn’t ever want another family to have to go through what we’re going through.
“I want to honour Theo’s name and to use this awful experience to be an advocate for women and help deliver the best care and support that women should expect to receive.
“To lose Theo so soon after he came into the world is something we’ll never get over.
“We’d been looking forward to becoming a family and to have that ripped away from us in such a cruel way was nothing short of traumatic.
“To this day, I still wake up and hope it’s all been a nightmare and then it hits me and I’m completely floored by the grief.
“Knowing that our baby boy will never even celebrate his first birthday is so difficult to come to terms with.
“Hearing everything again at the inquest has been unbearable, but we’re grateful to have some answers now.
“We would do anything to bring Theo back, but we know that’s not possible.
“All we can hope for now is that no other families have to go through the heartbreak we have. I wouldn’t wish it on anyone.”
‘EVERY SECOND COUNTS’
Amelia and Luke had attended King’s Mill Hospital at around 9.30pm on September, 13 last year after her contractions started.
They waited for over an hour to be seen before Amelia was given pain relief and underwent a sweep – she was allowed home at around 11.30pm.
But just after midnight Amelia started passing blood and experiencing unbearable pain and they returned to hospital.
Amelia was finally assessed at 1.42am before Theo was delivered at 2.02am.
A Healthcare Safety Investigation Branch (HSIB) report found there was no allocated lead in the maternity triage department, so nobody had responsibility for assigning roles and managing workload.
Both present triage midwives did not take responsibility on who would see Amelia upon her return to hospital, causing unnecessary delays in the rapid assessment.
Evidence given by an obstetrician from the Trust at the inquest stated that Amelia’s presenting symptoms should have prompted an immediate assessment.
The 29-minute delay in Theo receiving resuscitation medicines and blood products may also have impacted Theo’s outcome, the report added.
An obstetrician from the Trust told the coroner if Amelia had been assessed promptly, it was more likely than not that Theo would have survived.
Why caesareans are carried out
A caesarean section, or C-section, is an operation to deliver your baby through a cut made in your tummy and womb.
The cut is usually made across your tummy, just below your bikini line.
A caesarean is a major operation that carries a number of risks, so it’s usually only done if it’s the safest option for you and your baby.
Around one in four pregnant women in the UK has a caesarean birth.
A caesarean may be carried out because:
- Your baby is in the breech position (feet first) and your doctor or midwife has been unable to turn them by applying gentle pressure to your tummy, or you’d prefer they did not try this
- You have a low-lying placenta (placenta praevia)
- You have pregnancy-related high blood pressure (pre-eclampsia)
- You have certain infections, such as a first genital herpes infection occurring late in pregnancy or untreated HIV
- Your baby is not getting enough oxygen and nutrients – sometimes this may mean the baby needs to be delivered immediately
- Your labour is not progressing or there’s excessive vaginal bleeding
If there’s time to plan the procedure, your midwife or doctor will discuss the benefits and risks of a caesarean compared with a vaginal birth.
A caesarean is generally a very safe procedure, but like any type of surgery it carries a certain amount of risk.
Possible complications include:
- Infection of the wound or womb lining
- Blood clots
- Excessive bleeding
- Damage to nearby areas, such as the bladder or the tubes that connect the kidneys and bladder
- Temporary breathing difficulties in your baby
- Accidentally cutting your baby when your womb is opened
Source: NHS
Laura Robinson, the specialist medical negligence lawyer at Irwin Mitchell representing the family, said after the hearing: “It’s less than a year since Theo died, and losing him so suddenly and in such traumatic circumstances continues to have a profound effect on Amelia and Luke.
“The pain and grief they feel has been made worse by the questions they had around the events that unfolded in the lead up to their baby boy’s death.
“While nothing will ever make up for what Amelia and Luke are going through, we’re pleased to have at least been able to provide them with some of the answers they deserve.
“Sadly, however, the inquest has identified issues in the care prior to Theo’s death, especially around communication, training among maternity staff, and staff culture.
“Every second counts when delivering a baby in distress. It’s now vital that lessons are learned to help improve maternity safety and prevent other mums and dads from suffering the way Amelia and Luke have.
“We’ll continue to support them at this difficult time.”
