A newborn baby died just 16 hours after birth due to a catalog of errors by NHS maternity staff, an inquest has been heard. Giles Cooper-Hall died in October last year after inexperienced and “distracted” staff failed to care for his mother Ruth adequately, the Health Care Safety Investigation Branch said ( HSIB).
Staff at Plymouth NHS Trust University Hospitals failed to measure Ms. Cooper-Hall’s bump, a key indicator of healthy baby development, three times after the mother-to-be felt her baby was not moving as much as normal 41 weeks into her pregnancy. Giles’ health issues were not spotted until five days later when Mrs. Cooper-Hall came for an induction.
But other misunderstandings and errors on the part of staff meant the newborn’s heart rate inside the womb was not properly monitored. If done correctly, investigators said it “could have led to a different outcome”. In total, Giles’ heart rate was below a minimum level, where senior NHS staff should have been called, for 21 minutes. After he was born, doctors had to resuscitate him immediately and it took 20 minutes before his heartbeat was detected.
Giles was unable to breathe on his own and suffered blood loss and brain damage due to oxygen deprivation during labor. He died later the same day. Reacting to the report, Ms. Cooper-Hall and his wife, Allison Cooper-Hall, said: “We should have gone home to our baby – we will mourn him forever.”
The heartbreaking case comes a month after Ockenden’s independent report into England’s worst maternity care scandal at Shrewsbury and Telford Hospital NHS Trust. The devastating five-year survey has warned that childbirth will remain dangerous until changes are made. Couple Ruth and Allison Cooper-Hall were due to welcome son Giles to their family in October last year
The Cooper-Halls had raised concerns with maternity staff after Ruth felt her son was not moving as much as usual Today, a branch of healthcare safety investigations found that a catalog of mistakes and missed opportunities meant key chances to save Giles Cooper-Hall had been missed
IN BRIEF: KEY POINTS OF THE OCKENDEN REPORT
The Ockenden report, published in March, was the result of a damning five-year investigation into two decades of appalling care at Shrewsbury and Telford Hospital NHS Trust.
- Maternity expert Donna Ockenden, who led the review, said the trust ‘didn’t investigate, didn’t learn, and failed to improve’
- Some 201 babies and nine mothers could have – or would have – survived if the trust had provided better care
- Staff was afraid to talk about failures amid a ‘culture of undermining and bullying Doctors have been advised by trusted managers not to take part in a ‘staff voice’ initiative set up to help investigate what went wrong Issues were also noted with staffing levels, patient safety management, patient and family involvement in care and investigations, and complaint handling processes.
- The review team identified 15 “immediate and essential actions which must be implemented by all trusts in England providing maternity services”
- Ms. Ockenden said it is absolutely clear that there is an urgent need for a robust and funded England-wide maternity workforce plan starting now, without delay, and continuing over several years.
- The investigation, which looked at cases involving 1,486 families, mostly from 2000 to 2019, found “repeated errors in care” that resulted in injury to mothers or their babies.
Ms. Cooper-Hall, then 37, first alerted staff at Derriford Hospital, Plymouth, that her baby was not moving as much as usual despite being 41 weeks pregnant in October of Last year.
But staff reassured the mother-to-be that they were ‘not worried at all for her and the baby and sent her away. However, the HSIB report says staff failed to carry out proper checks because the unit was ‘busy’, including measuring her bump, a key indicator of the baby’s healthy development. Midwives then missed two more opportunities to measure her bump during appointments over the next four days.
It means a reduction in Giles’ growth was not noticed until five days after Ms. Cooper-Hall first sounded the alarm when she came to the hospital for an induction. A senior doctor, who did not see Ms. Cooper-Hall face to face, was concerned that Giles’ heartbeat had slowed and requested that his heartbeat be monitored throughout labor.
However, the HSIB report found that this plan had not been communicated to staff, adding that it was likely that the ‘multi-tasking’ carried out by the responsible clinician had acted as a ‘distraction’. Instead, the baby’s heart rate was only checked intermittently and without recommended equipment. In addition, new staff entering the service did not check Ms. Cooper-Hall’s written records, so she was wrongly treated as a ‘routine’ case, according to the inquest.
“Had the full plan of care been handed over between the clinicians caring for the mother, there may have been a different outcome for the baby,” the report said. “The care provided was not in line with local or national guidelines, which meant there was a delay in recognizing the baby’s abnormal heartbeat.”
Staff also failed to recognize the extent of the blood loss, which was a sign of placental damage and did not act as if there was an emergency when they struggled to find the baby’s heart rate. Instead, records showed his heart rate had been below the minimum level for 21 minutes before senior officials were called.
“Had an emergency been declared when there was uncertainty about the baby’s heart rate…[there would have been the] possibility of early delivery,” the report said. Giles Cooper-Hall died 16 hours after he was born, with experienced doctors not being alerted to his dangerously low heart rate until 21 minutes after the alarm should have been sounded.
Ms. Cooper-Hall initially sounded the alarm with maternity staff five days before after she felt Giles was not moving as much as she expected, but doctors told her they were “not as at all worried.” Doctors spent 20 minutes resuscitating Giles after he was born. He was unable to breathe unaided after suffering blood loss and brain damage due to oxygen deprivation during labor.
Allison Cooper-Hall is pictured here with Giles. Shortly after his birth, his parents had to make the heartbreaking decision to place him in hospice care. They were with him when he died, about an hour after his breathing tube was removed. After senior staff arrived, Giles was delivered by forceps and had to be resuscitated for 20 minutes before his heart was heard. He was unable to breathe on his own, suffered blood loss, and suffered brain damage due to oxygen deprivation during labor.
Later that day, his parents agreed he should start hospice care and were with him when he died at 8.30 pm on October 28, an hour after his breathing tube was removed. The couple said the investigation highlighted “failures of care, missed opportunities and the delay in recognizing the seriousness and urgency of the situation”.
“Our utter sadness and despair at losing Giles have been joined by anger and pain, as we now know that human error contributed to his death. We should have gone home with our baby – we will mourn him forever,” they added. Ms. Cooper-Hall has not been able to return to work as a licensed nanny since her son’s death. His wife also had to take an extended leave from her role as a high school teacher after being diagnosed with PTSD after witnessing the harrowing events.
The family said they had received no apology from the Trust, but were grateful to a consultant neonatologist who visited them at their home four days after Giles’ death to talk to them about what happened. had happened. “He said to us, ‘You should have gone home with your baby. His words will never leave us,” Ms. Cooper-Hall said. In total, the report made five safety recommendations to the Trust in an effort to prevent future deaths.
Giles’ death has been referred to the coroner and a date for the full inquest is expected to be released shortly. A spokesperson for Plymouth NHS Trust University Hospitals said all safety recommendations in the report will be fully implemented. The spokesperson also paid tribute to the Cooper-Halls.
“We were honored to have the opportunity to engage with the family and maintain an open dialogue as the investigation progresses; explaining how we will develop services that reflect the findings of the HSIB,” they said. “May we once again reiterate our deepest condolences on the sad loss of their son, Giles. The pain and distress they have experienced are immeasurable.