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."
- Baby dies of sepsis after hospital sent him home twice, mom claims
- Tearful mother accuses The Priory of 'putting profits before patients' as hospital faces multi-million pound fine for health and safety breaches in death of her 14-year-old daughter
- Pregnant mum unexpectedly dies during C-section birth of baby daughter
- Cwm Taf maternity: 'Significant progress' after failings
- NHS whistleblower 'witch hunt' fury: Hospital bosses fingerprinted doctors and demanded handwriting samples in bid to find who told widower about blunders in his wife's treatment
- Moment 17-year-old Meghan Markle happily greets mother Doria and grandfather while father Thomas films on camcorder during her last day at her LA high school is seen for first time in documentary
- Trump doesn't want to face another woman, claims Elizabeth Warren as she swings back at the president's prediction that Biden, Beto, Bernie or Buttigieg will survive to challenge him
- Rotherham sex gang victim says police should face criminal charges for 'aiding and abetting' abuse of hundreds of children as report reveals force ignored crimes for fear of stoking racial tensions
- East Kent Trust: Hospital baby deaths 'could have been prevented'
- Doctors Need Midwives: Ina May Gaskin on U.S. Maternity-Care Crisis
- Abby Johnson: Babies are being born alive after botched abortions. We deserve to know numbers and the truth
- 'I couldn't have shouted louder': Family seeks answers after care system fails son
- Girl, 13, dies from the flu days before her 14th birthday and an unvaccinated four-year-old goes blind during one of the worst virus seasons for decades that's killed 32 children
- Newborn Dies After Forceps Crushed His Skull During Delivery and Parents Receive Apology 5 Years Later
- I taught my husband to love me again, and now we have a baby! Wife who refused to give up after a stroke left her partner unable to speak or show affection reveals he's become a 'proud and amazed' dad
- The last midwife, and the first babies born in the world
- Mum thought she would die after childbirth left her with life-changing injuries
- Coronavirus ‘third wave’ hits as hospitals ‘fail to test patients and cases missed’
- Aleppo doctors appeal to US as violence continues during Russian 'pause'
- Anna Nicole Smith's ex Larry Birkhead reveals the last thing the Playboy model said to him before she died at age 39 in 2007
Baby died after senior doctor failed to see mother face-to-face amid ‘catalogue of errors’ have 1019 words, post on www.telegraph.co.uk at May 10, 2022. This is cached page on Europe Breaking News. If you want remove this page, please contact us.