Baby died after ‘gross failures' at Ysbyty Gwynedd in Bangor

North Wales Chronicle

27-05-2025

Etta-Lili Stockwell-Parry's death, on July 7, 2023, was found to have been contributed to by neglect following an inquest last week.
Kate Robertson, senior coroner for North West Wales, has since issued a Prevention of Future Deaths report to Betsi Cadwaladr University Health Board, in which she highlights 'many incidences of learning'.
The inquest heard that Etta was born at Ysbyty Gwynedd on July 3 in a 'poor condition', following an assisted birth.
She died four days later at Arrowe Park Hospital, Wirral, where she had been transferred.
Her cause of her death was recorded as hypoxic ischaemic encephalopathy (brain injury caused when a baby's brain doesn't receive enough oxygen or blood flow, either before, during, or shortly after birth).
Ms Robertson said there were 'several opportunities not taken' by those caring for Etta's mother prior to the birth – her pregnancy was described as 'uneventful' until June 21.
Static growth had not been identified, so there was no referral to obstetrics.
Etta's mother 'ought to have been referred to the labour ward for close monitoring,' Ms Robertson said, but instead was induced.
The coroner added: 'She received intermittent monitoring.
'The holistic assessments were not always completed and not entirely complete, the partogram did not note baseline foetal heart rate only as required, the maternal pulse was not always taken and recorded and there was no recognition that Etta's mother's pulse was being recorded as opposed to the foetal heart rate.
'There were several gross failures identified in Etta's mother's care which resulted in opportunities not taken to deliver Etta before she became distressed.'
While the health board undertook its own internal investigations into Etta's mother's care, Ms Robertson said its neonatal investigation was 'not thorough' and 'based on records alone'.
She noted that these records were 'often incomplete or included retrospective entries', and that statements from 'crucial individuals' were not obtained.
Some witnesses had only received and read the report several weeks prior to the inquest, meanwhile.
Ms Robertson added: 'Having issued reports to the health board regarding quality of investigation previously, this concern remains.
'Specifically, I have concerns that the neonatal element of the investigation was not thorough enough, such that without this, genuine learning and change will not and cannot occur.
'Even where learning has been shared, I am concerned that this is not contextualised sufficiently.
'I am also concerned that staff not involved in the incident will not learn fully enough from events where there is inadequate sharing of learning from an incident.'
The health board is duty-bound to respond to Ms Robertson's report by July 16, detailing action taken or planned to be taken.
Angela Wood, executive director of nursing and midwifery services at Betsi Cadwaladr University Health Board, 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.
'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.'