A coroner has slammed a hospital over the death of a baby after it was warned over its lack of midwives.
An inquest into the death of baby Ebony McCall revealed that Milton Keynes general hospital had been censured by the independent health watchdog in 2008 over its shortcomings in standards of care, but services on its maternity ward were still overstretched.
The coroner, Thomas Osborne, carried out an inquest in 2007 into the death of another baby, Romy Feast, who was born by caesarean section but died after monitor readings were misinterpreted.
The investigation by the Healthcare Commission was carried out after the death of that child. It found that a shortage of beds and midwives meant mothers were being discharged prematurely. The unit also had a readmission rate nearly three times the national average.
Today's inquest heard that Ebony McCall was born by caesarean section in May this year after her mother Amanda, aged 17 at the time, was admitted to hospital with stomach pains.
She was initially refused a caesarean section but went into labour that night after the baby's heartbeat became erratic, necessitating the emergency procedure she had wanted in the first place. McCall, a student, told the inquest she had agreed to a planned induction after meeting a consultant, Anthony Stock.
Ebony died shortly after her birth early on 9 May. Questioning the hospital's failure to act on the Healthcare Commission's findings, Osborne branded the midwife shortages "nothing short of scandalous". Hospital staff admitted failures in the care of McCall and Ebony.
Stock told the inquest: "The care in this case should have been consultant-led and right at the outset I am happy to acknowledge that the care did not come up to a standard that I would have expected." He said McCall was considered "low risk" in cardiac terms but when she came into hospital with stomach pain, would have been "high risk".
Osborne also said recommendations about bed numbers had not been met. Stock said: "I agree entirely that in an ideal world we would have greater accommodation. Milton Keynes is not unique. I think everyone acknowledges within the department we need higher staffing levels and more space."
After the inquest, the Care Quality Commission (CQC) which replaced the Healthcare Commission last year, condemned the hospital for failing to strengthen its maternity care.
Bernadette McGhie is a specialist in clinical negligence with Exeter-based lawyers Michelmores, and has a particular concern over mother-and-baby health issues.
"The death of Ebony is an absolute tragedy,” she says. “It’s clear that the unit was still entirely unprepared to cope with the pressure of work in the maternity ward and Ebony died as a result.
“There don’t seem to have been any improvements since last year’s damning assessment. These are just two cases involving the tragic death of a baby that has come to the attention of the coroner. We have no idea how many mothers and babies have suffered injuries as a result of the failings in this maternity department. Sadly, I deal with many cases of this kind but rarely has a coroner been so outspoken in his criticism. I hope that the NHS Trust will now take steps to protect new and unborn babies and their mothers so that no other family will needlessly suffer the loss of a baby in this way".
Categories: Birth injury