Baby died after being deprived of oxygen while ‘midwives joked about eating Haribo’ and talked about their salaries, inquest finds

An inquest has heard that a baby died after being deprived of oxygen during birth, while midwives joked about how many sweets the baby had eaten and how much money he had earned from them.

Theo Bradley had to be resuscitated in September last year after delays in his treatment at King’s Mill Hospital in Sutton-in-Ashfield, Nottingham.

Mother Amelia Bradley, 26, said she called for help several times because of the pain but could hear maternity staff chatting, with one saying: ‘I can’t believe how many Haribos I’ve had tonight.’

There were several midwives around the table when Mrs Bradley should have been assessed within 15 minutes of arriving at the hospital, but this was reportedly not done until 40 minutes later.

A gynaecologist from the Trust advised the coroner that if Mrs Bradley had been seen quickly, there was a good chance Theo would have survived.

Grieving parents Amelia Bradley, 26, and her partner Luke Sherwood, 26, (pictured centre) are now calling for lessons to be learned from the tragedy.

When it turned out she had not been treated, a midwife admitted that she had made a comment about a colleague who earned more than her.

Theo was diagnosed with a slow heart rate and it was decided to have the delivery take place via a category 1 caesarean section, when there is an acute danger to the life of mother or child.

After his birth, it turned out that the resuscitation equipment in the ward had disappeared and Theo was transferred to a specialized neonatal unit for treatment.

However, his condition deteriorated further and he died the next day in his parents’ arms, surrounded by his family.

Theo was diagnosed with a slow heart rate and it was decided to have the delivery take place via a category 1 caesarean section, when there is an immediate danger to the life of the mother or baby.

An autopsy revealed that he had died from severe brain damage caused by lack of oxygen.

An inquest concluded at Nottingham Coroner’s this week.

Nottinghamshire Assistant Coroner Elizabeth Didcock found that neglect contributed to Theo’s death.

She concluded that, all things considered, Theo would have survived if he had been born earlier.

Grieving parents Mrs Bradley and her partner Luke Sherwood, 26, from Kirkby-in-Ashfield, Nottingham, are now calling for lessons to be learned from the tragedy.

Mrs Bradley, who has applied to start training as a midwife in September, said: ‘After Theo died, Luke and I spoke about how we never wanted another family to go through what we had.

‘I want to honour Theo’s name and use this terrible experience to stand up for women and provide them with the best care and support they can expect.

‘Losing Theo so soon after his birth is something we will never get over.

‘We were looking forward to starting a family and having that taken away from us in such a cruel way was downright traumatic.

“To this day I still wake up hoping it was all a nightmare, but then it hits me and I am completely overwhelmed by the grief.

‘It’s so hard to accept that our little boy will never celebrate his first birthday.

‘It was unbearable to have to hear everything again during the investigation, but we are grateful that we now have some answers.

‘We would do anything to get Theo back, but we know that’s not possible.

“The only thing we can hope for now is that no other families have to go through the grief that we have. I wouldn’t wish it on anyone.”

An autopsy found he had died after suffering a severe brain injury caused by a lack of oxygen. An inquest at Nottingham Crown Court this week reached a narrative conclusion

Mrs Bradley and Mr Ashfield visited King’s Mill Hospital at around 9.30pm on September 13 last year after her contractions started.

However, the parents had to wait more than an hour before Mrs Bradley was given painkillers, examined and allowed home at around 11.30pm.

Shortly after midnight she started bleeding and was in excruciating pain.

They went back to the hospital and at 1:42 am she was finally examined, after which Theo was born at 2:02 am.

A report by the Healthcare Safety Investigation Branch (HSIB) found that there was no assigned manager for the maternity unit triage department, meaning no one was responsible for assigning roles and managing workload.

Both triage midwives present took no responsibility for who Mrs Bradley would see upon her return to hospital, causing unnecessary delays.

The statement given by a gynaecologist from the Trust during the investigation indicated that the symptoms Mrs Bradley was displaying should have prompted immediate investigation.

The 29-minute delay in administering resuscitation medication and blood products to Theo may also have affected his recovery, the report said.

The statement given by a gynaecologist from the Trust during the investigation indicated that the symptoms Mrs Bradley was displaying should have prompted an immediate assessment

A gynaecologist from the Trust advised the coroner that if a rapid assessment had been carried out there was a good chance Theo would have survived.

Laura Robinson, the medical negligence lawyer at Irwin Mitchell who is representing the family, said after the hearing: ‘It is less than a year since Theo passed away and the fact that he died so suddenly and in such traumatic circumstances continues to have a huge impact on Amelia and Luke.

‘The pain and grief they feel is compounded by the questions they had about the events leading up to their son’s death.

While nothing can ever make what Amelia and Luke are going through right now, we’re glad we were able to at least give them the answers they deserve.

Unfortunately, the investigation revealed problems in the care prior to Theo’s death, particularly in the areas of communication, training of maternity staff and staff culture.

‘Every second counts when delivering a baby in need. It is now vital that lessons are learned to improve pregnancy safety and prevent other mothers and fathers from suffering the same fate as Amelia and Luke.

‘We will continue to support them during these difficult times.’