Inquest Hears Lack Of Communication Between Hospital Wards Contributed To ‘Unnecessary’ Death Of Baby

Medical Experts Call On Hospital Trust To Show Lessons Have Been Learnt

21.12.2012

The distraught parents of a baby boy who died just 25 hours after he was born because midwives failed to monitor his breathing have backed calls for the NHS Trust to show improvements have been made in communication between wards after an inquest yesterday (20 December).

Melissa and John Reitano were told their baby son Jack was healthy despite his heart rate dropping to a dangerously low level during labour that meant he should have been monitored every two hours after his birth. Hospital staff failed to do this and Jack died next to his mum a day after he was born on 9 August after nurses laid him on her pillow to sleep.

Heartbroken and desperate to ensure the same mistakes by staff would not be repeated, the couple from Camden in London, instructed medical law experts at Irwin Mitchell to help find answers about why their baby died at St Mary’s Hospital and if more could have been done by staff within Imperial College Healthcare NHS Trust to save him.

The post mortem states that the cause of death was ‘Sudden Unexpected Early Neonatal Death’ which was accepted by the coroner in his narrative verdict but evidence heard at the inquest found there were failures in communication between the delivery room and maternity ward which meant Jack did not get the level of monitoring or care he needed.

The inquest, held at Westminster Coroner’s Court, heard Melissa was in labour for two days and Jack suffered breathing problems during the birth and for the first five minutes of his life, but doctors told Melissa and John he was completely healthy and there was no cause for concern.

However, medical records the couple have seen since Jack’s death note he was ‘in poor condition’ and there was an order for him to be placed in a transitional care ward for 12 hours where he could be monitored every two hours.

Ian Christian, a Partner and medical law expert at Irwin Mitchell’s London office representing Melissa and John, said: “They have understandably been left devastated by what happened and could not begin to come to terms with their loss until they had answers from the hospital trust about what went wrong.

“The inquest has gone some way to provide answers but we now need proof from Imperial College Healthcare NHS Trust that lessons have been learnt and improvements made to prevent the same mistakes from happening again and further unnecessary deaths.

“It is hard to believe that midwives and doctors failed to tell Melissa and John about their concerns and midwifes failed to read and act on simple instructions for Jack to be put in transitional care where he could have been monitored closely. It is obviously very difficult for the family to come to terms with the fact Jack might still be alive today, had that happened.”

John, an Account Executive, aged 37, said: “Melissa had a relatively normal pregnancy and we were so excited for the birth of our son. She was in labour for two days which was obviously very painful and tiring and we were concerned it could be distressing for Jack.

“I knew something was not right from looking at Jack’s heart monitor during labour but staff assured me everything was normal and did the same after he was born. We put our trust in the staff, but had we have known otherwise, we’d have done everything in our power to make sure he had the care he needed.

“Melissa and Jack were moved to the maternity ward but it wasn’t until 3am
when a midwife came over to try and settle Jack. She wrapped him in a blanket, laid him
on a pillow next to Melissa, reclined Melissa's bed and told them they should all get some sleep. At the time we figured we were advised appropriately but have since realised that co-sleeping in this manner may not have been advisable."

Melissa said: “I woke a couple of hours later and knew straight away that Jack wasn’t breathing. It felt like I was still having a nightmare. The nurses tried to resuscitate him but it was too late. We were absolutely heartbroken.

“We just couldn’t understand what had gone so wrong. The last four months have been a living hell as we’ve tried to come to terms with what happened. We just couldn’t understand how the maternity ward could completely ignore the order from the doctor in the delivery room and why Jack was allowed to co-sleep with me.”

We just hope improvements have been made in communications between different wards so no one else has to go through what we have. Nothing will bring Jack back put it will give us some peace of mind to know the same mistakes can’t be made again.”