Royal Derby Hospital: Missed opportunities led to baby's death

Missed opportunities led to the avoidable death of a baby in hospital, a coroner concluded.

Ethan Blackwell was born at Royal Derby Hospital on 21 May 2021 but died the next day after suffering brain damage.

Coroner Sabyta Kaushal said Ethan would have survived if delivered by Caesarean section seven hours earlier, but concerns were not escalated in time.

His parents, Jodie and Ben Blackwell, have joined calls for a national maternity inquiry.

Following a three-day hearing, Miss Kaushal found there were numerous missed opportunities but it did not amount to neglect and there was "no evidence of gross failure to provide basic medical care".

Her decision was based on the constant provision of one-to-one care by hospital staff, including two midwives, throughout Mrs Blackwell's labour, said the Local Democracy Reporting Service.

Miss Kaushal documented a lack of involvement of the parents in the decision-making process, with no evidence they provided informed consent in relation to Caesarean section plans being scrapped twice at 03:28 and 05:45 on the day of Ethan's birth.

She found there was no documentation to show the reasoning for the reversals of the Caesarean section plans, which had followed two bradycardia - significant and sustained drops in Ethan's heart rate.

This was "not documented nor explained", she said.

Staff were also "falsely reassured" by a previously reliable scalp electrode attached to Ethan's head.

Miss Kaushal did not find sufficient evidence to write a prevention of future deaths report after gaining assurances from the trust during the hearings.

Speaking after the conclusion, Mrs Blackwell said: "We have waited a long time for answers, but we are satisfied that the inquest has highlighted the areas where Ethan was failed and we as parents were ignored.

"Ethan was our first-born son who we couldn't wait to bring home. He should have never been an opportunity for lessons learnt or a case study in order to make improvements.

"What our baby went through should never have happened."

She added: "We believe there should be a national inquiry into the country's maternity service.

"Babies are losing their lives too often, and it is something that should be looked at closer; a lessons learnt report is simply not good enough."

Garry Marsh, executive chief nurse for the University Hospitals of Derby and Burton NHS Foundation Trust, said: "We are profoundly and deeply sorry for the tragic loss of Ethan and for the continued heartbreak that we know the shortcomings in his care have caused.

"We fully accept that we missed opportunities to deliver Ethan sooner, and we have been determined to make changes in the years since his tragic death in 2021 to make our care safer, particularly around measuring a baby's heartbeat during labour and how we involve families in decisions about their care."

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