Expert Lawyers Will Continue To Investigate Baby’s Death On Behalf Of Devoted Parents

By Helen MacGregor

The heartbroken parents of a baby boy who died aged just two days old have spoken of their grief and ‘loss of faith’ in midwifery services following an inquest into his death where the Coroner made a series of recommendations to help prevent a similar tragedy.

Jared McDowall died unexpectedly at St Michael’s Hospital in Bristol in January last year, despite his parents Natasha and Shaun repeatedly raising concerns with staff that he wouldn’t feed and was regularly crying like he was in distress. His mum said she was so concerned for his health that she didn’t dare go to sleep and cradled him in her arms.

The couple, who live in, Bristol, instructed medical law experts at Irwin Mitchell to investigate whether more could have been done to save Jared. Today (26 September) they spoke of their ongoing heartache and their hopes that University Hospitals Bristol NHS Foundation Trust takes onboard the Coroner’s recommendations and ensures every step is taken to prevent any other family from going through a similar tragedy.

Recording a narrative verdict at Bristol Coroner’s Court today, Coroner Maria Voisin said: “Jared McDowall died of natural causes. At the time, he had a number of medical conditions not diagnosed.”

She confirmed she will write a report to prevent future deaths that will include a number of recommendations*.

The inquest heard an investigation was launched by the hospital after Jared’s death which found the root cause as a ‘failure to recognise deteriorating baby’ with the underlying factors recorded as being:
• Midwives failed to recognise poor feeding;
• There was a failure by midwifes to assess Jared’s feed chart;
• Midwives failed to assess Jared following Natasha’s concerns that he was hot and not feeding;
• There was a team/social factor that there appeared to be a ‘group think’ that Natasha was merely being ‘an anxious first time mum’.

The investigation also recommended the post-natal team learn lessons in that they need to listen to and respond to women’s concerns regarding their baby’s well being and a full neonatal assessment should include review of both the feeding chart and neonatal observation chart.

During the inquest, a neonatologist called to give evidence confirmed that more training would now be given to midwives in recognising the symptoms of hypoglycaemia (low blood sugar levels caused by lack of food). It was also confirmed the Trust has updated its neo-natal observation charts so that if a baby is noted as having an abnormal cry it is a red flag symptom for them to immediately undergo tests.

Julie Lewis, a Partner at Irwin Mitchell’s Bristol office representing the couple, said: “What happened to Jared is both heartbreaking and shocking and all those responsible for his care must take every step possible to learn from any mistakes made to ensure no other helpless baby is lost in similar circumstances.

“Jared’s parents have shown tremendous courage during the inquest listening to the circumstances surrounding the death of their son and whilst we welcome the Trust’s confirmation that lessons have been learnt we would like to see proof that all recommendations made by the Coroner are implemented.

“Of course northing can bring their son back and we will now continue to work on behalf of Natasha and Shaun in liaising with the Trust to secure an admission of responsibility which we hope will help them to begin to come to terms with what happened and begin to rebuild their lives.”

Jared was born by emergency C-Section on 15 January last year after Natasha showed symptoms of the condition pre-eclampsia (high blood pressure) which caused Jared’s heartbeat to become erratic.

He and Natasha were sent to the recovery ward but over the course of the next two days his condition deteriorated as he struggled to feed and was repeatedly sneezing mucus.

Natasha was so concerned for him that she didn’t dare go to sleep and cradled him in her arms but in the early hours of 17 January she returned from the bathroom to find him lifeless in his cot and despite resuscitation attempts he was declared dead a short time later.

Since Jared’s death Natasha, 37, who works in Human Resources and Shaun, 43, an IT Consultant, have struggled with depression which has affected their jobs and everyday lives.

Natasha said: “We were absolutely disgusted at the care Jared and I were given and it has been very hard to relive the events during the inquest.

“Shaun and I knew something was seriously wrong with Jared and I was becoming more and more concerned because he wouldn’t feed, but the midwives made me feel like I was overreacting and that I was wasting their time.

“Jared was our first baby and we were so excited to bring him back to our family home but we never got chance to do this. His death still affects us every day and I’m not sure we’ll ever come to terms with it. To be honest what happened made us lose all faith in maternity services and we were terrified the same thing would happen again if I became pregnant.

“We just hope that Jared’s death was not in vain and that improvements are made in observational charts and training to ensure no other family has to go through the same ordeal. Nothing can bring Jared back but seeing improvements in maternity services might help us to begin the process of accepting what happened.”

*The Coroner’s recommendations will include:
The red flag point for babies to receive further testing, such as a blood sugar test, should be determined by a baby’s weight for their gestation and its gender as boys typically weigh more than girls. It is currently 2.5kg for all babies regardless of these factors. She said charts need to be presented graphically (as opposed to the current numerical presentation) in order to improve clarity.

The report will also include recommendations for better joint working between doctors and midwives and the introduction of education packages in in relation to hypoglycaemic involvement and recognising the symptoms of a baby that is unwell.

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