Baby died after senior doctor failed to see mother face-to-face amid ‘catalogue of errors’

A newborn baby died after a senior doctor failed to see his mother face-to-face, an investigation has found.

Officials found that maternity staff repeatedly missed chances to save the life of Giles Cooper-Hall, who died following a catalogue of errors in the maternity care of his mother at University Hospitals Plymouth NHS Trust.

The failings emerged just weeks after the Ockenden Report found that more than 200 babies died as a result of failings at Shrewsbury and Telford Hospital NHS Trust.

The latest report highlighted how similar issues at University Hospitals Plymouth NHS Trust meant staff missed multiple opportunities to save Giles.

It revealed how his mother Ruth Cooper-Hall, then aged 37, was not seen face-to-face by a consultant when she went into labour in October last year, despite recommendations made in an interim Ockenden Report published nearly two years earlier.

A Healthcare Safety Investigation Branch (HSIB) report into the incident, published on Tuesday, has exposed how inexperienced and over-stretched staff failed to carry out proper checks, recognise there was an emergency or seek help from senior doctors until it was too late.

One member of staff even pressed the patient buzzer instead of the emergency alarm when they were unable to hear the baby's heartbeat.

The HSIB report also suggested Giles' death could have been avoided if staff knew about the care plan for his mother's labour.

Instead, vital messages were not passed on, with the investigation finding this was likely to be because the staff responsible were "distracted" by other tasks.

In total, the report issued five safety recommendations to the trust in a bid to prevent future deaths.

Mrs Cooper-Hall and her wife, Allison Cooper-Hall, 39, said the investigation had highlighted "the failures in care, missed opportunities and delay in recognition of the severity and urgency of the situation".

"Our utter sadness and despair at losing Giles has been joined by anger and hurt as we now know that human error contributed to his death," they said. "We should have come home with our baby – we will grieve for him forever."

Mrs Cooper-Hall first alerted staff at Derriford Hospital, in Plymouth, that her baby was not moving as much as normal when she was 41 weeks pregnant. But she was discharged and reassured the team was "not concerned at all".

In fact, the HSIB investigation found staff had not carried out proper checks as the unit was "busy", including failing to measure her bump – a key indicator of healthy baby development.

'Source of distraction'

Midwives then missed two further opportunities to measure her bump at appointments in the next four days. A reduction in its growth was only noticed on the fifth day, when Mrs Cooper-Hall came to the hospital for an induction.

A senior doctor who looked at her notes – but did not see her in person – was also concerned the baby's heartbeat may have slowed, so they advised his heart rate should be continuously monitored throughout labour.

But this plan was not passed on to staff on the ground, with the investigation finding it was likely the "multiple tasks" being carried out by the responsible clinician had acted as a "source of distraction".

Instead, the baby's heart rate was checked only intermittently and without the recommended equipment, while new staff coming on duty repeatedly failed to check Mrs Cooper-Hall's written records so she was wrongly treated as a "routine" case, the investigation found.

A spokesman for University Hospitals Plymouth NHS Trust said: "We would like to extend our gratitude to the investigating team for their support of both the family and the staff involved.

"All the safety recommendations stemming from the investigation will be fully implemented as part of our commitment to foster a culture of learning, development and improvement within the maternity setting."