A health chief has apologized to the parents of a one-day-old baby who died after a series of mistakes and missed opportunities at a scandal-hit NHS hospital.
Alison Williams admitted that Jessica Webb, who was 30 weeks pregnant, should have been transferred to a specialist unit to deliver her premature baby.
An inquest heard that little Nelly Webb was born by caesarean section at the Royal Glamorgan Hospital in South Wales.
At the hearing it was announced that mMaternity services were put under special measures after a damning review was revealed At least 60 stillbirths were not properly reported or investigated.
The 2lb 9oz infant, born on New Year’s Day 2019, died after one of her lungs collapsed and a drain was inserted, possibly injuring her.
Little Nelly Webb was born at just 30 weeks gestation weighing just 2lb 9oz, but tragically died the next day
Jessica and her husband Rikki (pictured together) were told that Nelly died because she was premature. No post-mortem examination was carried out and the cause of death was reported to the coroner as natural causes
Jessica and her husband Rikki were told that Nelly died because she was premature. No post-mortem examination was carried out and the cause of death was reported to the coroner as natural causes.
But 18 months later, the couple were shocked to receive a letter stating that mistakes had been made and that, the inquest heard, she would have been ‘salvageable’ with the right treatment.
Ms Williams, a former chief executive of the Cwm Taf Morgannwg University Health Board, told the hearing: ‘It’s heartbreaking for the family – I’m truly and sincerely sorry for everything they’ve had to go through.’
South Wales assistant coroner Sarah Richards told Ms Williams it would have been ‘preferred’ if a high-risk pregnant woman had been admitted to the University Hospital of Wales in Cardiff, 12 miles away.
Ms. Williams responded, “Looking at the information, I agree with you.”
The tragedy occurred at a time when staff at Royal Glamorgan were not properly reporting infant deaths in the hospital’s neonatal unit.
Ms Williams said that at the time of Nelly’s death, on January 2, 2019, there was a serious shortage of midwives and a reliance on local doctors, some of whom were still in training.
Ms Williams resigned in August 2019 following a damning report into maternity care at the Royal Glamorgan and its sister hospital, Prince Charles in Merthyr Tydfil.
Dr. Nick Lyons, who investigated Nelly’s death, also apologized to her parents after they were kept in the dark about the events leading to her death.
He said: ‘I just feel for the family, I struggled for hours with whether we should inform them but it was the right thing to do. I would like to apologize to them for the stress this must have caused.’
Kerri Eilertsen-Feeney, head of obstetrics at the hospital, told the inquest: ‘My concerns were about the lack of reporting – incidents were not investigated in a thorough and meaningful way.
‘Morale was poor, staff were afraid to report because they would face judgement.
In a statement outside court, Nelly’s parents said: ‘Nelly was our firstborn and we were absolutely heartbroken when she died. We were told she died of natural causes due to her premature birth.”
‘I was not involved in the day-to-day management of the unit. I tried to resolve the governance issues and meet with the families we had identified who had been the subject of previous incidents.”
In written evidence, Jessica, 31, said she and her husband were taken to see their baby after being told her oxygen levels were low.
She said: ‘She was in her cot, we didn’t feel like there was anything serious at the time.
‘I was so happy to see my baby again after a difficult pregnancy.’
But Nelly suddenly deteriorated and the couple watched as a team of doctors frantically tried to revive her.
Jessica said: ‘We stood there as they administered drugs – it was horrible to watch. We felt so out of control that we couldn’t believe what we were seeing.
“After a few moments, a doctor took us into a side room, apologized and said Nelly wouldn’t make it.”
On January 2, the hospital started reporting serious incidents about Nelly’s death.
But Dr. Iyad Al-Muzaffar, one of the consultants who tried to resuscitate the one-day-old baby and counseled her parents, said he was not aware of the report.
Dr. Al-Muzaffar said Nelly had aggressive respiratory distress syndrome and a pneumothorax (a collapsed lung).
He said she died of a “rare complication” and that he believes the baby did not die from an injury caused by the chest tube.
Just over a year after Nelly’s death, parents Jessica and Ricky were contacted by health chiefs at the Royal Glamorgan Hospital in South Wales to say mistakes had been made during her care.
The consultant said: ‘We could have done things differently but it wouldn’t have made any difference to the outcome. Whenever I look at a case, there are always lessons to be learned.”
The six-day inquest, in Pontypridd, seeks to discover whether there were systematic failings at the Royal Glamorgan, which had one of the highest death rates in Britain.
In a statement outside court, Nelly’s parents said: ‘Nelly was our firstborn and we were absolutely heartbroken when she died. We were told she died of natural causes due to her premature birth.
‘We really struggled after losing Nelly, so much so that Jessica couldn’t return to work.
‘Just 18 months later we were again shocked and devastated when, out of the blue, we received a letter from the health board saying mistakes had been made.
“We are still deeply traumatized by what happened and by the fact that we were lied to for so long. The legal process has revealed what really happened to our little girl, which is even more disturbing.
‘We were so worried that history would repeat itself and that we would have lost all confidence in the care at the Royal Glamorgan Hospital, that we traveled to Cardiff to have our two boys in 2020 and 2023.’