Serious hospital failings contributed to baby’s death, inquest told

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SERIOUS failings contributed to the death of a four-day-old baby at Dewsbury and District Hospital, a coroner has ruled.

An inquest this week heard how medical staff failed to properly oversee the high-risk birth of little Victoria Jonah.

Bradford Coroner’s Court was told how drops in the baby’s heart rate were not taken as seriously as they should have been and that the registrar on duty had struggled to manage two simultaneous high risk births.

Instead of asking an on-call consultant to help, Victoria’s mother Carol was waiting to be seen by the registrar for 45 minutes after concerns about the baby’s heart rate were raised.

Mrs Jonah, of Nettleton Road, Mirfield, went to Dewsbury Hospital for an induced labour on December 23, 2010, because Victoria had stopped growing.

After other induction methods failed and she declined the option of a Cesarian section, Mrs Jonah was given a syntocinon drip on Boxing Day and went into labour that evening.

At midnight, midwife Irene Hopkins noticed the baby’s heart rate was slowing and noted it as ‘suspicious’. On Tuesday, she accepted the heart rate should have been deemed ‘pathological’, meaning it would have been treated as an emergency.

She did call registrar Dr Davison Nyambo to Mrs Jonah’s delivery room, but he did not arrive until 45 minutes later because he was dealing with another complex birth.

When he arrived, he also described the heart rate as suspicious, not pathological.

On Tuesday, he said he only realised the heart rate was pathological later on and said not bringing in an on-call consultant to help was an ‘oversight’.

On Wednesday, independent expert Professor James Walker told the inquest that it should have been ‘obvious’ to staff that the heart rate was pathological and a that Cesarian section should have been performed.

This, he said, would have meant Victoria was not deprived of oxygen for as long and, on the balance of probabilities, would have prevented her death.

Instead, the birth went ahead naturally and Victoria was not delivered until 1.43am. She was transferred to the Royal Hallamshire Hospital in Sheffield where she died on New Year’s Eve.

Coroner Peter Straker recorded a verdict of death by natural causes contributed to by serious failings. He said the hospital medical team were not as involved as they should have been and that too much responsibility was given to the midwife.