‘Systemic failures’ in death of day-old baby at Welsh maternity unit
A day-old girl died after “systemic” failings in a troubled maternity ward and would likely have survived if her mother had been moved 12 miles to a specialist centre, a coroner has concluded.
There were a number of mistakes in the care of Nelly Webb and missed opportunities to save her after her premature birth at the Royal Glamorgan hospital in South Wales, an inquest in Pontypridd heard.
Nelly was born with respiratory distress syndrome and weighed 1.13 kg (2 lb 8 oz), but South Wales assistant coroner Sarah-Jane Richards said she “probably would have survived” if her mother, Jessica Webb, had gone to Cardiff had been transferred to give birth.
The coroner concluded there had been “systemic failures” and said: “The statement from the baby’s mother made a damning read of a service in disarray. There was insufficient attention to the tests, medications and treatment from a team that appeared fragmented with multiple doctors and nurses providing different care plans.
“She was not eligible for transfer. There was no discussion between obstetrics and neonatology about the impending delivery and the likely need for intubation, ventilation and specialist care.
“The consultant on duty should have arrived at the hospital at the time Nelly was intubated and been at the bedside to supervise the procedure. There was insufficient supervision of the doctors in training at the time and poor follow-up the next day.”
The coroner said delaying the insertion of a chest tube was a “missed opportunity”. When the drain was placed, it was in the wrong place.
In written evidence, Webb, 31, said she was taken to see her baby after giving birth by caesarean section on New Year’s Day 2019. She said: “I was so happy to see my baby after a difficult pregnancy.”
But Nelly suddenly deteriorated and the couple watched as doctors tried to revive her. “We stood there as they administered drugs – it was horrible to see. We felt so out of control that we couldn’t believe what we were seeing,” Webb said.
She said they had initially come to believe that her death was “an unfortunate and unavoidable consequence of her premature birth” and that they were “completely shocked” to discover that the care Nelly received was inadequate.
Outside court, birth injury lawyer Diane Rostron said: “Jessica and Rikki (Nelly’s father) lost their first-born daughter in circumstances that could have been prevented. They are deeply traumatized by their loss. We hope this finding leads to important lessons. The family will now pursue a medical negligence claim against the hospital.”
Rostron is working on a total of 18 birth injury claims against the Royal Glamorgan Hospital and its sister site, the Prince Charles Hospital in Merthyr Tydfil – and a further 14 against other Welsh boards.
Maternity care at the Royal Glamorgan Hospital in Llantrisant was put into special measures four months after Nelly’s death, when dozens of worrying cases were identified. There are no longer any special measures in force.
Paul Mears, the chief executive of Cwm Taf Morgannwg University’s health board, apologized to Nelly’s family.
He said: “Since 2019, we have made significant changes to maternity and neonatal services within our health board. This work has been led by a major improvement programme, overseen by an independent maternity care monitoring panel, commissioned by the Welsh Government.
“Our neonatal units are now based in the Prince Charles and Princess of Wales Hospitals (in Bridgend), each with a dedicated consultant and specialist neonatologist, raising the level of senior clinical leadership in our units every day of the week. ”