Parents Supported By Irwin Mitchell Speak Of Heartbreak Following Inquest

The devastated parents of a baby who died minutes after being born at Prince Charles Hospital in Wales have called for lessons to be learned after a Health Board admitted a number of failings leading up to his death.

Jenson James Francis was pronounced dead around 40 minutes after he was delivered in a poor condition by emergency caesarean section at the hospital in Merthyr Tydfil  on 21 June, 2018.

Following his death, Jenson’s mum Tiffany Gillard, instructed expert medical negligence lawyers at Irwin Mitchell to investigate the care she and her son received under Cwm Taf University Health Board, which runs the hospital.

The Health Board has admitted a number of failings in Jenson’s care, including he should have been delivered more than two-and-a-half hours earlier than he was. The Board has apologised to Tiffany, 21, and her partner, James Francis, 22, of Mountain Ash.

It comes after an inquest concluded that Jenson died as a result of failures to deliver him in a timely manner.

Expert Opinion

“What was meant to be a joyous occasion turned into heartbreak for Tiffany and James.

“For a number of months they have had many concerns about the care that Jenson received. Sadly evidence heard at the inquest and the Health Board’s own admissions have validated these concerns.

“Whilst nothing will ever change what the family have been through, we welcome the Coroner’s conclusions and note that a number of areas have been identified to improve patient care.

“We now call on the Health Board to ensure all staff are aware of what changes need to be made and that all recommendations are implemented, so hopefully others don’t have to suffer the devastation that Tiffany, James and the rest of the family have gone through.

“We will continue to support the family at this extremely upsetting time.” Richard Sweetman - Associate Solicitor

Find out more about Irwin Mitchell's expertise in handling medical negligence cases 

Tiffany said: “There is not a day goes by when we all don’t think of Jenson. Trying to come to terms with what happened and Jenson’s death has been incredibly traumatic.

“We put our faith in health professionals but it is difficult not to think that we were badly let down by those who were supposed to help us.

“While we remain absolutely heart-broken that Jenson is no longer with us, he will always be part of our family. We will never forget him.

“We just hope that the Health Board learns lessons as we would not want any other family to suffer the pain we face daily following Jenson’s death.”

David Regan, assistant coroner, recorded a narrative conclusion.

Background

An inquest held at Pontypridd Coroner’s Court was told how an investigation into Jenson’s death was subsequently carried out by Cwm Taf University Health Board. A root cause analysis investigation report was published.

The report stated that Tiffany was due to be induced on 18 June, 2018, but this was delayed by two days because of an electrical failure on the special care baby unit.
She attended hospital the following day, 19 June 2018, after her waters broke. Following examination, it was decided she could be sent home to return as planned for an induced labour the following day.

Tiffany was transferred to the hospital’s labour ward at around 8pm on 20 June. There had been concerns by midwifery staff about the variability of Jenson’s heart rate. However, these were not escalated to other staff, the report said.

During her labour Tiffany developed a raised temperature and signs of sepsis, along with further “abnormal” fetal heart rate readings. The report found that at various times from 00:15am on 21 June  onwards, midwifery staff classified Jenson’s heart rate monitor reading as “pathological”.

However, obstetric staff regarded the pattern as “reassuring” and “labour was allowed to continue.”

Just before 1.30am, midwifery staff contacted an on-call consultant. Following a phone conversation the consultant decided they did not need to attend hospital to see Tiffany. Instead they told midwifery staff to contact them if there were further concerns.

At 1:45am, 2:15am and on multiple other occasions throughout the night, Jenson’s heart rate was classed as “pathological”, however, no action was taken.

The report added that just after 4.10am, following discussions between medical staff, a consultant and registrar decided Tiffany should undergo a grade two caesarean section, i.e. within 75 minutes.

Jenson was born really poorly at 5.20am. However, despite attempts to resuscitate him he was pronounced dead at 6am.

The report into his birth highlighted that there were a range of failings in care, including issues related to midwifery staffing levels and issues caused by the use of temporary accommodation during the rebuild of the hospital’s maternity unit.

In addition, the report identified several root causes of Jenson’s death including the staff’s inability to recognise his gradually worsening condition during the labour and a lack of effective communication. It added that lessons which must be learned included improvements to the current structure of training in fetal monitoring.

The report found that a consultant and registrar called for category 2 caesarean section within 75 minutes. This should have been a category one within 30 minutes.

Cwm Taf University Health Board has subsequently admitted a number of failings in Jenson’s care.

These were:
• A failure to consider induction of labour on 19 June, 2018.
• Document keeping fell below a standard to be expected
• There was a failure at 1.45am on 21 June, 2018, to obtain a senior review of Tiffany and consider delivering Jenson
• There was a failure to perform a category 1 caesarean section
• There was a failure to deliver Jenson by 2.45am on 21 June.