'Gross failures' and 'neglect' played part in death of newborn baby
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.
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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.
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."
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."
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