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Coroner Finds Delays In Baby's Delivery Significantly Reduced His Chances Of Survival

Calderdale & Huddersfield NHS Foundation Trust Admits Liability For Baby’s Death


The heartbroken parents of a baby boy who died just three days after his birth at Calderdale Hospital say they hope improvements will be made after an inquest heard delays and failures during his treatment contributed to the boy’s death.

Sarah Ellis and Adam Asquith, from Batley, instructed specialist medical negligence lawyers at Irwin Mitchell’s Leeds office to investigate the care provided during the birth by the Calderdale & Huddersfield NHS Foundation Trust amid concerns about the treatment.

At a two-day inquest at Bradford City Courts, Coroner Oliver Longstaff said there were several missed opportunities to get medical intervention for Gino's mother by staff at Calderdale Royal Hospital.

He recorded a verdict of death due to misadventure and highlighted staff at Calderdale hospital missed four opportunities that may have improved Gino’s chances of survival.

Firstly, he said there was a missed opportunity for a midwife to seek medical input when Sarah arrived at the Maternity Assessment Centre, a missed opportunity to transfer Sarah to labour ward, a third missed opportunity to perform a Caesarean section after medical review just after midnight and a fourth opportunity when Sarah had symptoms of fetal bradycardia and delivery could have made by Caesarean-section.

He added: “At the very least the delays in Gino being delivered made the chance of him being born alive significantly reduced.”

Sarah Ellis, 28, went into labour on 7 November 2014 and attended Calderdale Hospital where she was told there was no bed for her and that she needed to go to Huddersfield Birthing Centre.

After a four hour wait at the Birthing Centre she was sent home on 8 November as her labour was not in an advanced stage. Later that day she could no longer feel her baby moving and was told to attend Calderdale Hospital. Upon arrival she was told she was not dilated enough and left in the Maternity Assessment Unit.

Over the next six hours the couple were assessed by six midwives, a registrar and senior house officer, but the signs of distress being shown were not identified.

Sarah was eventually examined by a consultant and underwent an emergency Caesarean section following the identification of meconium.

Her son, Gino, was born on 9 November in a very poor condition and was resuscitated twice. Gino was placed on life support, but tragically Sarah and Adam were advised to withdraw treatment. Gino died on 12 November due to severe oxygen deprivation shortly before being delivered.

Ahead of the inquest the NHS Trust admitted liability for Gino’s death in the civil case after an internal investigation found Sarah’s condition was not escalated to the obstetric team, communication was not clear between staff, that there were delays transferring Sarah to a delivery room and that she was not correctly monitored at the hospital.

Emily Whisker, an expert medical negligence lawyer at Irwin Mitchell representing the family said: 

Sarah said: “Words cannot explain what we have been through in losing our first child together in this terrible way. It is hard to accept that the delays we faced and the failure to pick up signs that Gino was in distress led to his death.

“The investigation in Gino’s death and the care we received from the Trust found a number of failures and we hope that these issues will be corrected so other people do not have to endure what we went through in November 2014.

"The ordeal we have been through has been completely devastating and we are still trying to come to terms with what happened to our family. We can only hope that by speaking out we will ensure lessons are learned and that mothers and their babies are in the best possible hands when they are at their most vulnerable.”

If you or a loved one has suffered as a result of negligent delivery, we may be able to help you claim compensation. See our Medical Negligence Guide for more information.

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