Baby who died at scandal-hit hospital 'likely to have survived with better care'
A premature baby who died at a scandal-hit maternity ward a day after being born would “likely” have survived with better care, an inquest has concluded.
Rikki and Jessica Webb’s baby daughter Nelly Webb was born at 30 weeks’ gestation via C-section at the Royal Glamorgan Hospital in Llantrisant on January 1, 2019. But a series of failures led to her death the following morning - including being admitted to a unit which didn’t have the appropriate experience or skill to look after her.
After Nelly died, correspondence between the hospital and the coroners' office showed the hospital describe Nelly's death as a “naturally occurring death of a preterm baby”, but the week-long inquest, which has finally shed light on what actually happened more than four years later, heard how no mention was made of intervening events which could have contributed to Nelly's death. As it was agreed at the time that Nelly died from natural causes, no inquest date was set and the circumstances around Nelly’s death went unknown.
But, later that year, the maternity services across the Cwm Taf Morgannwg health board region were put into special measures - including at the Royal Glamorgan Hospital and the Prince Charles Hospital - after a review of services since 2010 exposed how there had been at least 60 stillbirths that had happened that had not been properly reported or investigated, reports WalesOnline. More than a year after Nelly’s death, Mr and Mrs Webb were contacted by the health board which informed them that mistakes had been made in the lead up to their daughter's passing, and an inquest was then opened, finally concluded on Monday, November 20, at Pontypridd County Court.
The CEO of Cwm Taf Morgannwg at the time of Nelly’s death, Allison Williams, told the inquest that the Royal Glamorgan Hospital was operating a 28-week gestation model at the time but that in her view babies which required tertiary unit care should have been transferred to an appropriate neonatal intensive care unit. Ms Williams accepted that a review into the hospital had assessed the Royal Glamorgan as having neither the facilities nor the experienced staff for the delivery of less than 32-week gestational age babies.
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The inquest also heard from Dr Iyad Al-muzaffar, a neonatologist at the hospital at the time, who explained that the unit's capacity to treat premature babies was constantly reviewed on a daily basis depending on doctors, nurses and others on shift. If babies were expected to be born at the hospital before 32 weeks it was required that a discussion should take place to decide whether a transfer in "utero" (before the baby is born) to a different unit and hospital was more appropriate.
Dr Al-muzaffar added that after Nelly died he would have expected a post-mortem examination to be carried out to confirm or rule out whether an iatrogenic injury (a puncture injury in Nelly’s lung caused by an accidentally misplaced chest drain) caused Nelly's death. But a post-mortem examination never took place. A review of Nelly's care by an independent doctor found that an iatrogenic injury was a likely cause of her death, but Dr Al-muzaffar disagreed and said this was a rare complication and on the balance of probability he did not believe this caused Nelly's death.
The inquest heard that there was an instruction from the on-call consultant for the registrar caring for Nelly on the night she was born to administer intubation. However, due to complications this was not done and a lower level of breathing support – CPAP then BYPAP – was administered throughout the night instead. The on-call consultant attended the hospital on the morning of January 2 to support Nelly's care and then intubation was carried out. At this point Nelly had deteriorated, the inquest heard.
On the final day of the hearing coroner Dr Sarah Jane Richards summarised a list of findings determined by the evidence. The 13 findings included: inappropriate application of the 28-week model for a unit which had neither the facilities nor the skilled and experienced staff to deliver a premature baby of 30 plus six weeks; the failure to recognise that Nelly was deteriorating between the evening of January 1 and morning of January 2 reflects inadequate training, experience and vigilance of the overnight team; misplacement of a chest drain resulted in it not functioning as it should have and with the possibility of causing iatrogenic injury; discussing the death with the coroner’s office without any mention of intervening events which could have contributed to Nelly’s death.
Dr Richards recorded a medical cause of evidence as 1a bilateral tension pneumothorax, 1b severe respiratory distress syndrome, and 1c prematurity. Recording a narrative conclusion, the coroner told the court: "The death of a premature baby who would have likely survived her prematurity had she been transferred in utero to a neonatal intensive care unit."
Speaking on behalf of Nelly's parents following the inquest, Diane Rostron, birth injuries solicitor, said: “We welcome the coroner’s finding that systemic failings at the Cwm Taf Morgannwg University Health Board led to the preventable death of one-day-old Nelly Webb in 2019. The coroner heard that serious concerns relating to the maternity services delivered by the health board were known nearly a year before Nelly was born.
"The inquest also heard that Allison Williams, the health board’s chief executive at the time of Nelly’s death, agreed that as a high risk pregnancy, Jessica should have been transferred before Nelly was born to another hospital with more experience in maternity and neonatal care. Jessica and Rikki lost their first born little girl in circumstances that could have been avoided. They have been left deeply traumatised by their loss. We hope that this finding leads to key learnings. The family will now pursue a medical negligence claim against the hospital."
Ms Rostron's firm also has 11 other ongoing birth injury claims against the Royal Glamorgan Hospital and six claims against Prince Charles Hospital.
Paul Mears, chief executive of Cwm Taf Morgannwg health board, said: “We fully accept the findings of the coroner, and extend our sincere apologies to Nelly’s family for failings in care which led to her tragic death. The loss of a baby is devastating, and we do not underestimate the pain that her family continues to suffer as they come to terms with their loss. No words can take away the grief caused by Nelly’s death, but we can reassure her family and everyone in our communities that we are committed to learning from such tragic events to ensure that they do not happen again.
“Since 2019 we have made significant changes to maternity and neonatal services in our health board. This work has been guided by a major improvement programme, overseen by an independent maternity services oversight panel (IMSOP) that was commissioned by Welsh Government. Our neonatal units are now located at Prince Charles and Princess of Wales Hospitals, each with a dedicated consultant and a specialist neonatologist, increasing the level of senior clinical leadership on our units every day of the week.
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“Our training and education programme for all staff has been expanded to cover a broader range of neonatal skills, procedures and simulation-based training and all of our teams have access to the latest clinical policies and guidelines. Systems are also in place to strengthen joint working between our maternity and neonatal teams and, through improved clinical data, we continually monitor outcomes and quality, enabling us to respond quickly to improve the safety and effectiveness of the care we provide. We continue to offer support to Nelly’s family, and once again express our heartfelt apologies for their devastating loss.”
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