Baby died after ‘communication issues' with remote-working consultant

Telegraph

7 days ago

A coroner has issued a warning about NHS consultants working remotely from home after a baby died following a delayed Caesarean section.
Daisy McCoy's mother visited hospital reporting reduced and unusual foetal movement, and a scan showed that Daisy had sustained at least one brain injury, an inquest heard.
However, there was a delay in carrying out the C-section operation at Yeovil Maternity Unit in Somerset because of 'communication issues' between staff, including the consultant who was working remotely.
Deborah Archer, the area coroner for Devon, Plymouth and Torbay, warned that there was a gap in policy on staffing after the consultant did not 'fully consider' if she should come in to assist because she was unaware of staffing problems on the ward.
Shortly after her birth, Daisy was transferred to a larger hospital and then to a children's hospice, where she died 13 days after the procedure.
Phone call was not initiated
Yeovil Maternity Unit closed temporarily in May this year because 'high staff sickness', which Adam Dance, the local MP, told the Commons was partly due to a 'toxic work culture'. It is due to open in November.
The inquest heard that Daisy was born via Caesarean section at the unit in Somerset on Feb 9 2022.
After her mother had reported abnormal foetal movement, there was a delay in the operation because of a communication failure between staff and a lack of training around the significance of this presentation.
A scan showed that Daisy had suffered a brain injury because of lack of oxygen or blood flow, and her parents were left on their own for an hour with no explanation of how serious the injury was.
In a prevention of future deaths report, Ms Archer said: 'The consultant who was working remotely was not fully aware of the staffing issues on the ward, and this meant that she did not fully consider with all the information whether she should have come onto the unit to assist in person.'
She said there was no guidance to ask a consultant to attend in this matter, and 'no one had time to escalate matters ... or make an accurate note', which meant that a telephone call – which should have happened 30 minutes after Daisy's abnormal scan – was not initiated.
None of the staff checked the criteria for a normal foetal heartbeat, and therefore did not escalate the results of the test. The consultant told the inquest that, if she had been aware of the outcome, she would have come on to the ward at that point.
'Significant damage'
On Feb 9, Daisy was moved to the larger Southmead Hospital in Bristol before being transferred at some point to a children's hospice in Barnstaple, Devon, where she died on Feb 22.
Ms Archer recorded a narrative conclusion that the 13-day-old had died because of an interruption in blood flow to the brain, which caused 'significant damage', and perinatal asphyxia before her delivery.
The inquest found that the brain injury was already present when Daisy's mother attended the maternity unit, and earlier delivery would not have impacted her chances of survival.
The area coroner warned that further deaths may occur given the lack of training on abnormal foetal movements, absence of policies on escalation of emergencies, and a gap in the policy on consultants attending when the ward is understaffed.
Her report has been sent to the associate medical director of Musgrove Park in Taunton, the other hospital run by Somerset NHS Foundation Trust, where many mothers from the closed Yeovil unit have been sent. They have until Sept 30 to respond.