'Gross failures' and 'neglect' played part in death of newborn baby
'Gross failures' and 'neglect' played part in death of newborn baby
A Prevention of Future Deaths (PFD) report has been issued to Betsi Cadwaladr University Health Board after the death of a newborn baby girl
(Image: PA )
The death of a newborn baby girl was in part caused by "gross failures" in medical care and "neglect". A coroner said she was so concerned about the circumstances surrounding the death of Etta-Lili Stockwell-Parry in 2023 that she issued a Prevention of Future Deaths (PFD) report to the Betsi Cadwaladr University Health Board (BCUHB).
Her mother Laura Stockwell-Parry was induced and Etta-Lili was born "in poor condition" on July 3, 2023,at Ysbyty Gwynedd, Bangor having suffered oxygen starvation, according to a pathologist.
She was taken to Arrowe Park Hospital on the Wirral but died there four days later on July 7. At a two day inquest in Cernarfon Kate Robertson, senior coroner for north west Wales, found that neglect was a contributory factor in the little baby's death.
Staff had failed to notice problems early enough and a subsequent investigation wasn't thorough enough, the coroner said. Neither a community midwife before the birth, nor maternity unit staff at Ysbyty Gwynedd noticed the baby had stopped growing at about 40 weeks, the hearing was told. Sign up for our free daily briefing on the biggest issues facing the nation sign up to the Wales Matters newsletter here.
(Image: Daily Post Wales )
Article continues below
North Wales Live reported that the health board said said "significant steps" had been taken to address the failures in this case, which it said was an "isolated incident".
Mrs Robertson found cause of death was hypoxic ischaemic encephalopathy. She recorded a narrative conclusion at this week's inquest. In a Prevention of Futue Deaths report statement, issued after the inquest the coroner said there were "several gross failures" identified in Etta's mother's care.
These failures resulted in opportunities not taken to deliver Etta before she became distressed. There were "many incidences of learning" relating to Etta's resuscitation at Ysbyty Gwynedd, she added.
Mrs Robertson found: "There were several opportunities not taken by those caring for Etta's mother.
"There were opportunities to identify concerns with Etta through her mother on the midwifery led unit on 2 July 2023 including properly conducting holistic assessments, properly completing partogram and manual palpation of maternal pulse which would also likely have resulted in earlier detection of distress and successful delivery. Etta's death was contributed to by neglect."
The coroner also found that Mrs Stockwell-Parry ought to have been referred to the labour ward for close monitoring, but instead, she was induced and received only intermittent monitoring. Her pulse was not always taken and recorded and there was no recognition that Etta Lili's mother's pulse was being recorded as opposed to the fetal heart rate.
Mrs Robertson also found the neonatal investigation was not thorough. The investigator neither obtained nor requested statements from the doctors directly involved in Etta's resuscitation, nor did they meet them to understand what had occurred.
Mrs Robertson said she is concerned that staff not involved in the incident will not learn enough from events where there is inadequate sharing of learning from an incident. She issued the Prevention of Future Deaths report about her concerns.
BCUHB has 56 days to respond with a timetable of how it will act on points raised.
Angela Wood, Executive Director of Nursing and Midwifery Services at Betsi Cadwaladr University Health Board, said "significant steps" have been taken to address the issues in this "isolated incident".
She said: "We would like to extend our deepest sympathies and heartfelt condolences to Mr and Mrs Stockwell-Parry following the tragic death of baby Etta. We recognise the profound impact this has had on the family, and we are truly sorry for the pain and loss they have endured.
"Since this tragic event in July 2023, we have carried out a thorough review of the care provided and taken significant steps to ensure that the issues identified have been addressed. We are committed to learning from this and have implemented a range of measures to strengthen our training and clinical oversight to ensure the safest possible care for mothers and babies."
Article continues below
She added: "We want to reassure expectant mothers and families in our care that this was an isolated incident. Providing safe, compassionate care is our highest priority, and we remain committed to upholding the highest standards of care across our maternity services."
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Leader Live
3 days ago
- Leader Live
Former nurse removes cyst from her eye after years on waiting list
The dangerous procedure was revealed in a report looking at the long delays facing people awaiting treatment for conditions in North Wales. The Citizen Experiences Report, presented during a meeting of the Betsi Cadwaladr University Health Board on Thursday, found frustrated patients were taking matters into their own hands due to long waits for help. It also described long waits experienced by patients in the emergency departments at Ysbyty Gwynedd, Ysbyty Wrexham Maelor, and Ysbyty Glan Clwyd. Patients waiting up to 36 hours had been reported and 'overcrowding, uncertainty, and discomfort' were also 'common concerns'. The public consultation had been part of a 'listening and understanding' initiative aimed at improving the design and delivery of care and services. There had been 300 enquiries from MPs and MSs over their constituents' experiences, with waiting times 'the main focus'. One had described a former nurse, now 84, who had been placed on the ophthalmology waiting list in June 2019, but who had waited around three years until being seen. 'She says that she then had some procedures which did not help, and eventually removed a cyst on her eye herself,' the report quoted. 'She is waiting for an eye operation, which was requested in October 2023, and her eyesight is deteriorating rapidly. 'As a former nurse and nurse manager, she has given her working life to care for other people. Now she needs some care of her own.' Another concerned a man who wished to enlist with the British Army, but was unable to because of the health of his teeth. The report said: 'He has not been able to find an NHS dentist nearby due to a chronic shortage of dentists in North Wales, and private dentists have quoted a minimum of £3,000 for treatment.' Waiting had also had a 'catastrophic impact' on one patient's life who suffered daily pain, and another, awaiting an operation for bladder stones, endured 'continual bleeding'. Community conversations also highlighted issues over outpatient waiting times, access to services, ambulance and emergency department delays, and communication. Llais, the body which gives people a 'voice', when accessing health services, had also gathered data. Comments included 'significant challenges' accessing timely and affordable primary care, difficulty accessing GP appointments and the absence or loss of NHS dental provision. Delayed treatment or self-management of dental problems had manifested 'sometimes in unsafe or distressing ways'. Comments included: 'I ended up filling my own tooth with a kit from the chemist.' Another patient reported waiting: '12 hours in a corridor on a trolley.' Long delays for specialist services, including audiology, cataract surgery, neuro-developmental assessment, and respiratory care were also ' a major concern'. The meeting heard that despite many views highlighting 'dissatisfaction or frustration', many other participants had also expressed 'gratitude' and praise for the 'professionalism and compassion' by hospital staff, members and teams. The report also described measures taken by the board to address calls for improvements. In dental care this included creating contracts worth over £1.5 million to expand NHS dental provision. Further procurement exercises, covering general dental services, orthodontics, oral surgery, and non-urgent access, also totalled over £5 million. MOST READ A new dental access portal, launched in February, was also helping 'simplify and centralise' access to care. Improvements to areas such as emergency departments, dermatology, gynaecology, physiotherapy musculoskeletal, cancer services, and a midwifery ward bereavement suite had also been implemented. In neuro-developmental services, providing mental health support for children and young people, a Child and Adolescent Mental Health Services (CAMHS) improvement programme was in place. The new Crisis Hub – Alternatives to Admission – service had also supported 266 people in its first quarter since opening in February. The board acknowledged that 'significant work' remained to address 'challenges' in a 'sustainable, long-term way'.
Glasgow Times
3 days ago
- Glasgow Times
Mother of jailed British activist admitted to hospital while on hunger strike
Laila Soueif's family said she had been admitted to St Thomas's Hospital in London on Thursday night with dangerously low blood sugar levels, but continues to refuse medical intervention. Ms Soueif has been on hunger strike for 242 days in protest against the imprisonment of her son, Alaa Abd El-Fattah, who has been in jail in Egypt since September 2019. Speaking to reporters outside the hospital on Friday, Ms Soueif's daughter Mona Seif said she feared her mother was on the brink of death and urged the Prime Minister to act immediately. Ms Seif said: 'The bottom line is we are losing her and there is no time. 'Keir Starmer needs to act now, not tomorrow, not Monday, now.' In December 2021, Mr Abd El-Fattah was sentenced to five years in prison for spreading false news and should have been released last year. Laila Soueif (centre) taking part in a vigil for her son outside the Foreign Office in 2023 (Jordan Pettitt/PA) UN investigators have declared his imprisonment in breach of international law and earlier this year Sir Keir Starmer promised he would 'do everything I can' to ensure his release. Ms Seif said: 'If he is unable to deliver, if he is unable to bring my brother (home), then he needs to show that Britain is angry, that Britain is not going to let go of its citizen.' In a statement on Friday, Ms Soueif's family said she had received glucagon treatment, which induces the liver to break down stored fat to obtain glucose, but continued to refuse treatment that would provide her with calories. She has lost 42% of her bodyweight, now weighing 49kg, and has not eaten food since September 29 2024. She was previously admitted to hospital in February, with doctors warning she was at 'high risk of sudden death', and in early March agreed to move to a partial hunger strike following a call between Sir Keir and Egyptian president Abdel Fattah El-Sisi. But she resumed her full hunger strike on May 20, saying: 'Nothing has changed, nothing is happening.' Mr Abd El-Fattah has been on his own hunger strike for 90 days following his mother's admission to hospital in February. The Prime Minister raised Mr El-Fattah's case with the Egyptian president again in a call last week, and Middle East minister Hamish Falconer discussed his release with Egypt's foreign minister Badr Abdelatty on Sunday. A spokesperson for the Foreign Office said: 'We are concerned to hear of Laila's hospitalisation. We remain in regular contact with Laila and her family and have checked on her welfare. 'We are committed to securing Alaa Abd El-Fattah's release and continue to press for this at the highest levels of the Egyptian government.'
Wales Online
3 days ago
- Wales Online
Woman did something unbelievable to herself after waiting years for eye treatment
Woman did something unbelievable to herself after waiting years for eye treatment A new report has also found that some patients at a Welsh health board are waiting 36 hours for treatment in the emergency department The report was presented at a Betsi Cadwaladr University Health Board meeting this week (Image: Ian Cooper/North Wales Live ) An elderly woman resorted to removing a cyst from her own eye after enduring years of waiting for treatment. The perilous procedure was highlighted in a report which examined the extensive delays faced by individuals awaiting medical treatment for various conditions in North Wales. The Citizen Experiences Report, presented at a Betsi Cadwaladr University Health Board meeting on Thursday, revealed that exasperated patients were taking drastic measures due to prolonged waiting times. The report was part of a "listening and understanding initiative to improve health services. The report also detailed lengthy waits endured by patients in the emergency departments at Ysbyty Gwynedd, Ysbyty Wrexham Maelor, and Ysbyty Glan Clwyd. Reports of patients waiting up to 36 hours were noted, with "overcrowding, uncertainty, and discomfort" being "common concerns". Stay informed on the latest health news by signing up to our newsletter here . There had been 300 enquiries from MPs and MSs regarding their constituents' experiences, with waiting times being "the main focus". One account described an 84-year-old former nurse who had been added to the ophthalmology waiting list in June, 2019, but had waited approximately three years before being seen. "She says that she then had some procedures which did not help, and eventually removed a cyst on her eye herself," the report read. "She is waiting for an eye operation, which was requested in October, 2023, and her eyesight is deteriorating rapidly. As a former nurse and nurse manager, she has given her working life to care for other people. Now she needs some care of her own." Another case involved a man who aspired to join the British Army but was hindered by his dental health. The report said: "He has not been able to find an NHS dentist nearby due to a chronic shortage of dentists in North Wales, and private dentists have quoted a minimum of £3,000 for treatment." The long wait also had a "catastrophic impact" on one patient's life who experienced daily pain, while another, awaiting surgery for bladder stones, suffered from "continual bleeding". Community discussions further highlighted issues relating to outpatient waiting times, access to services, ambulance and emergency department delays, and communication. Llais, the organisation that provides a "voice" for individuals when accessing health services, also collected data. Feedback revealed "significant challenges" in obtaining timely and affordable primary care, difficulties in securing GP appointments, and the lack or loss of NHS dental services. One person said: "I ended up filling my own tooth with a kit from the chemist." Another patient revealed how they'd spent 12 hours in a corridor on a trolley. Long waiting times for specialist services, including audiology, cataract surgery, neuro-developmental assessment, and respiratory care were also flagged as "a major concern". The meeting was informed that while numerous comments pointed to "dissatisfaction or frustration", there was also a wave of "gratitude" and commendation for the "professionalism and compassion" displayed by hospital staff, members, and teams. The report went on to outline steps taken by the board in response to demands for better services. In dental care, this involved establishing contracts valued at over £1.5 million to bolster NHS dental services. Additional procurement processes for general dental services, orthodontics, oral surgery, and non-urgent access amounted to more than £5 million. February saw the introduction of a new dental access portal, which has been helping to "simplify and centralise" the process of obtaining dental care. Improvements have been made across various departments including emergency, dermatology, gynaecology, physiotherapy musculoskeletal, cancer treatments, and a midwifery ward bereavement suite. For neuro-developmental services, which offer mental health support to children and adolescents, an improvement programme for Child and Adolescent Mental Health Services (CAMHS) was underway. Additionally, the newly established Crisis Hub – Alternatives to Admission – service had provided assistance to 266 individuals within its first three months since launching in February. Article continues below The board recognised there was still "significant work" to be done in tackling "challenges" in a manner that was a "sustainable, long-term way".
