Consultant was ‘working from home' when baby died in hospital

Times

4 days ago

A baby girl died after a delayed caesarean section after 'communication failures' with a consultant who was working from home, a coroner has said.
Daisy McCoy was born by caesarean section at Yeovil special care baby unit in Somerset on February 9, 2022 after her mother reported feeling reduced foetal movement, an inquest heard.
A scan showed that before her birth, Daisy had sustained at least one brain injury, possibly due to problems with the umbilical cord or placenta. Her parents were left on their own for an hour with no explanation of how serious Daisy's injury was.
There was a delay in carrying out the caesarean section after the staff's 'failure to communicate', said Deborah Archer, area coroner for Devon, Plymouth & Torbay.
She recorded a narrative conclusion that the 13-week-old girl had died due to an interruption in blood flow to her brain that caused 'significant damage' and perinatal asphyxia before her delivery.
Archer has issued a prevention of future deaths report, in which she said: 'There was a delay in Daisy's caesarean being performed due to a combination of factors, which involved a failure to communicate appropriately between staff and a lack of training on recognising the significance of abnormal foetal movements and foetal compromise generally.
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'Although the inquest ultimately determined the brain injury to Daisy was already present when she attended Yeovil maternity unit and that an earlier delivery would not have made a difference to her survival … the timing of the injury was an issue at inquest and the delivery process raised a number of concerns.'
According to her report, such concerns included that '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 added: 'During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.'
Shortly after her birth, Daisy was transferred to Southmead Hospital, a larger hospital in Bristol, and then a children's hospice in Barnstaple, where she died 13 days after the caesarean.
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A scan had shown the baby had suffered a brain injury due to lack of oxygen or blood flow 'which on the balance of probabilities had occurred before delivery', the inquest heard. The interruption to blood flow was 'potentially due to a problem with the umbilical cord or placenta'.
Only the registrar knew that the abnormal scan required a call to the consultant within 30 minutes, but this did not occur, leading to a delay in the casaserean section.
None of the staff checked the foetal heartbeat according to set criteria and therefore did not escalate the test results, the inquest was told. The consultant told the inquest that if she had been aware of the outcome of the scan, she would have gone to the ward at that point.
The coroner's report set out seven matters of concern at the unit, including 'a lack of training to recognise unusual foetal movements, and on rapid escalation of emergency events'.
There was also 'a gap in policy to provide for both consultants and or midwives to attend in person where understaffing may lead to patient safety being compromised' and 'a lack of adequate communication between different health care professionals on the maternity unit', she added.
The unit has since closed temporarily due to 'high staff sickness', Adam Dance the Liberal Democrat MP for Yeovil, claimed in the House of Commons in June that this was partly due to a 'toxic work culture'. The hospital said the baby unit will be closed for at least six months from May.
The coroner's report has been sent to the associate medical director of Musgrove Park in Taunton, the other acute hospital run by the Somerset NHS Foundation Trust, and where many mothers from the closed Yeovil unit have been sent in the interim. They have until September 30 to respond.
Somerset NHS Foundation Trust said: 'We want to extend our sincere condolences to Daisy's family at this difficult time.
'We note the coroner's report, and we are already working hard to address the points raised, includingimprovements in training, managing escalation, promotion of appropriate professionalchallenge, communication and training, as well as ensuring our colleagues fully understandrelevant policies and procedures.'