A baby has died after maternity staff repeatedly missed the chance to intervene to save his life, a formal investigation has found.
Giles Cooper-Hall was just 16 hours old when he died after a catalog of errors in maternity care for his mother, Ruth Cooper-Hall, at Derryford Hospital in Plymouth.
A report by the Health Safety Investigation Division (HSIB) on the incident, released on Tuesday, reveals how inexperienced and overworked staff failed to conduct proper inspections, acknowledge an emergency or seek help from senior doctors until it’s too late.
This comes just weeks after Ockenden’s independent report on more than 1,800 cases revealed serious shortcomings in maternity care provided by Shrewsbury Hospital and the Telford NHS Trust.
A new HSIB report highlights how similar problems at Plymouth NHS University Hospitals mean staff have missed many opportunities to save Giles.
It revealed how Ruth Cooper-Hall, then 37, was not personally seen by a counselor when she gave birth in October last year, despite recommendations made in Auckden’s interim report published in December 2020.
The HSIB report also suggests that Giles’ death could have been avoided if staff had known about his mother’s birth care plan. Instead, vital messages were not delivered, and the investigation found that this was probably due to the fact that the responsible staff was “distracted” from other tasks.
Cooper-Hall and her wife, Alison Cooper-Hall, said the investigation highlighted “failures in care, missed opportunities and delays in acknowledging the gravity and urgency of the situation.”
“Our utter sadness and despair at the loss of Giles was joined by anger and pain, as we now know that human error contributed to his death,” they said. “We had to go home with our baby – we will grieve for him forever.
Ruth Cooper-Hall first warned staff at Derifd Hospital that her baby was not moving as much as usual when she was 41 weeks pregnant. But she was discharged and assured that the team was “not worried at all.”
In fact, the HSIB investigation found that the staff did not carry out proper checks because the department was “busy”.
The advice of a senior doctor that the baby’s heart rate should be monitored constantly is not transferred to the staff on the ground. The investigation found that the “multiple tasks” performed by the responsible clinician probably acted as a “source of distraction”.
Instead, the baby’s heart rate is checked only periodically and without the recommended equipment, while new staff on duty repeatedly fail to check Cooper-Hall’s written records, so it is mistaken for a “routine” case. the investigation.
“If the full care plan was passed between clinicians caring for the mother, there may have been a different outcome for the baby,” the report said.
Giles was delivered with forceps and had to be resuscitated for 20 minutes before his pulse could be heard. But he could not breathe alone, suffered blood loss, and suffered brain damage from oxygen starvation at birth. Later that day, his parents agreed to begin palliative care, and they were with him when he died at 8:30 p.m. on October 28.
Ruth Cooper-Hall, now 38, added: “At the time, we had concerns about the care we received in the delivery kit, including staff inexperience, lack of communication, lack of confidence and an environment of excitement and panic, but we left Derifd, after leaving us with the impression that what happened to Giles was just a tragic accident.
“We thought it all happened in the last 10 minutes of the birth, but the report reveals so much more time of mistakes, missed opportunities and delays.
Peter Walsh, chief executive of the Patient Safety Charity Action Against Medical Accidents, said: “This is another tragic and preventable loss of a baby … Too few staff and poor communication between overworked staff. Maternity care is in a bad way and should be a top priority for more resources and improvement. “
A spokesman for the University Hospital Plymouth NHS Trust said: “All safety recommendations arising from the investigation will be fully implemented as part of our commitment to promote a culture of learning, development and improvement in the maternity ward.
“The most important thing is that we would like to thank Cooper-Halls. Let us once again express our sincere condolences on the sad loss of their son Giles. The pain and suffering they have experienced is immeasurable. ”
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