Inquest Hears Of Catalogue Of Failings By Maternity Staff Within NHS Trust Put In Special Measures

Specialist Medical Negligence Lawyers At Irwin Mitchell Call For Improvements To Maternity Services


The heartbroken parents of a baby boy who died following extensive bleeding on his brain and hypoxia, after he could not be delivered by caesarean section as planned due to the operating theatres being full, have demanded improvements are made to maternity services at the hospital.

Hayley Jones and her partner Daniel Keddle are speaking out for the first time today following an inquest into the death of their son Harley who died of catastrophic brain damage in March this year, shortly after being delivered at Hereford County Hospital.

Medical negligence lawyers at Irwin Mitchell representing the couple say they are ‘deeply concerned’ by a catalogue of failings identified in an internal investigation carried out by The Wye Valley NHS Trust following Harley’s death – the Trust which was recently placed in special measures following concerns about its higher caesarean and forceps delivery rates than the national average.

During a resumed inquest at Hereford Coroner’s Court today (9 December) HM Coroner Mr Wooderson also expressed concern about the findings of the review and called for proof that an action plan the Trust drew up in the wake of Harley’s death has been implemented to prevent the same failings from happening again. 

He concluded that Harley died from a massive hypoxic-ischaemic brain damage, the ventouse delivery caused a large subaponeurotic haemorrhage (bleed on the brain). The post mortem findings were consistent with multi-organ failure consequential upon the complications of birth.

The inquest heard evidence that Hayley’s pregnancy was considered high risk as there was a history of pulmonary embolism (blood clots in the lung) in her family. A care plan was drawn up that suggested the 19-year-old should be induced no later than the 21 March to avoid any potential problems to mum and baby. However Hayley went in to labour naturally and her baby began to show signs of distress. Hospital staff realised there were no available operating theatres for caesarean and said there was no other option for her but to give birth using ventouse.

A consultant failed with a ventouse on two occasions until finally a theatre room became free. But sadly, the damage was done and despite Harley being delivered by emergency caesarean on 22 March, he had suffered extensive hypoxia and  bleeding on the brain and resuscitation attempts failed. The cause of the bleed was the ventouse.

The Serious Incident investigation into Hayley and Harley’s case carried out by the Trust made a number of recommendations for areas of improvement including:
• Communication between staff in emergency cases;
• Contingency plan needs to be developed to ensure the safety of both mother and baby if an emergency caesarean section is required;
• The fetal heart rate should be monitored at all times in emergency situations to detect whether the baby is in distress.

Expert Opinion
This is a tragic case that had devastating consequences for a young couple very much looking forward to welcoming home their first child.

“The results of the serious incident report carried out by the Trust were shocking, but what’s more concerning is that the couple have been given only limited reassurance that the recommendations have been taken on board. Although additional make shift theatre space has been created, it is still unclear what the hospital will do in the future should all operating theatres be full when a patient needs a caesarean and this is not acceptable.

“This is highlighted further by the fact the Trust has now been placed in special measures with the Care Quality Commission highlighting maternity services as a key area of concern. It is vital improvements are made to protect patient safety and we urge the CQC to ensure that is the case.

“We hope that the inquest has gone some way to providing Hayley and Daniel with the answers they sought about the Trust’s actions and we will now continue to work on their behalf investigating Hayley and Harley’s care in the hope of securing accountability and answers about what more could have been done to help them, so they can finally begin the long process of rebuilding their lives.”
Mandy Luckman, Partner
Hayley said: “Daniel and I were really looking forward to welcoming our son into the world and being parents for the first time, but we have both been left completely devastated by the ordeal we were put through at the hospital which we believe ultimately led to Harley’s death.

“During Harley’s delivery, the maternity staff were extremely chaotic and I believe if they had acted differently and I was referred quickly up to theatre for a c-section then Harley would be still with us.

“We were not surprised to learn that the Trust has been placed in special measures as we’ve not been told standards have improved, so it was only a matter of time. But for Harley’s death to not be in vain improvements must be made to maternity services at Hereford Hospital to prevent any other family from being put through the same hell and losing their precious baby.”