Posted on 03/20/2021 2:15:49 AM PDT by nickcarraway
An inquest heard vital life-saving equipment was missing from a resuscitation room at Ystrad Fawr Birth Centre when Zak-Ezra Carter was taken there shortly after his birth
Warning: This article contains an image and details which some readers might find upsetting
A young mother whose baby died following childbirth was turned away from hospital three times while in pain from labour, an inquest has heard.
Zak-Ezra Carter died at the Royal Gwent Hospital in Newport two days after his birth at Ystrad Fawr Birth Centre in Ystrad Mynach at about 7.15pm on July 20, 2018.
The baby’s mother, Adele Thomas, said she was turned away on three separate occasions during the day leading up to the birth, an inquest into his death at Gwent Coroners’ Court heard on Thursday.
Ms Thomas told the court she had gone into labour early that morning and grew more frustrated as her pain and discomfort grew over the course of the day.
The inquest heard that when she was admitted a record of observations was not properly completed during labour by attending midwives.
Monitoring of the baby’s heart rate, which should have occurred every five minutes during stage two of labour according to the evidence, was not recorded by either midwife in attendance.
Senior coroner Caroline Saunders said this amounted to a “gross failing in basic care” and represented a “missed opportunity” to effect a change in the treatment of the child.
Giving evidence one midwife said equipment vital to resuscitation was missing from a resuscitation room and was inaccessible to doctors who came to assist.
A statement from Zak-Ezra’s mother, Adele Thomas, was summarised at the hearing by senior coroner Caroline Saunders.
Ms Thomas said she went to the birthing centre at Ystrad Mynach with her partner at about 5am on July 20, 2018, as her waters had broken about an hour and a half before. She said she was given tests and told to return later that evening.
Ms Thomas said she was assessed again at 9.20am but was again told she wasn’t ready to be admitted and “had to go home”.
“I recall not wanting to go home,” she said. “I remember feeling I would be better off in hospital and I was told to walk around the hospital grounds, the cafe, or take a walk to Tesco.
“I thought this was ridiculous as it is about a one-and-half mile walk to get to Tesco. I then decided to just go home.”
The court heard Ms Thomas’ partner called the centre again at 11.30am and Ms Thomas said she heard nurses tell him that if they arrived nurses would examine her again but would then send her home.
Ms Thomas said she waited for “as long as she felt able” but returned to the birthing centre at about 12.30pm. There she said she was given a birthing pool and was told she would be better off at home as she was only 3cm dilated.
She said she was once again told to walk around the hospital but was finding it difficult to walk.
“I started to feel scared,” she said. “This was my first pregnancy and I was in pain. I was deeply unhappy that they kept sending me home.”
At about 4.30pm she said she returned to the hospital again with her partner and mother. On this occasion she was admitted after nurses found she was 7cm dilated.
“I do not remember much from this time,” she said. “I do remember asking for pain relief and being offered paracetamol. I thought I should be on gas and air by this point.”
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Ms Thomas also said she heard nurses arguing in the room with her during the course of the labour. Theresa Ward, a former registered midwife at Ysbyty Ystrad Fawr Birthing Centre, gave oral evidence to the court.
Ms Ward explained that at the time she was working at the birth centre but has since retired. She said she understood Ms Thomas’ labour was progressing at the time of her admission onto the unit because she was “distressed” and she “looked like she was progressing”.
Ms Ward said stage two of labour began at 6.05pm. She checked in on the room as she had been “concerned” about some observations she made of fellow midwife Lisa Gibson during an earlier birth.
“I went into the room earlier than I would have because I had already been working with Lisa once before,” she said. “And there was one or two issues with the birth that I wasn’t happy about and I had gone to the managers about it.
“I put my concerns to the managers after what had happened and I wasn’t too happy about Lisa being there during the pushing stage.”
On arrival in the room Ms Ward said she was not able to locate the partogram – the document used to record observations during labour.
She said she also had concerns about Ms Thomas’ position on the bed so changed her position to sit more upright. During stage two of labour Ms Ward said the foetal heart rate should be monitored every five minutes and recorded on the partogram.
Ms Ward said she noticed the foetal heart rate was not being monitored so she began to record it with a sonic aid. She said she did this every five minutes from there on but did not make an attempt to look for the partogram or record her observations on a replacement document.
Shortly before the point of birth Ms Ward said she stopped being able to hear a heart rate and informed her colleague. “I was looking for it and I didn’t hear the foetal heartbeat,” she said.
“Lisa said she could hear it faintly in the distance. I thought: ‘Well, I didn’t’ but she did.
“When she (Ms Thomas) sat back I put the sonic aid and there was no foetal heart. I thought: ‘There isn’t a foetal heart there and there wasn’t before’. I just told Lisa to get the baby out.”
Why we cover inquests – and why it's so important that we do As painful as these proceedings are for those who have lost a loved one the lessons that can be learned from inquests can go a long way to saving others’ lives.
The press has a legal right to attend inquests and has a responsibility to report on them as part of their duty to uphold the principle of open justice.
It’s a journalist’s duty to make sure the public understands the reasons why someone has died and to make sure their deaths are not kept secret. An inquest report can also clear up any rumours or suspicion surrounding a person’s death.
But, most importantly of all, an inquest report can draw attention to circumstances which may stop further deaths from happening.
Should journalists shy away from attending inquests then an entire arm of the judicial system is not held to account.
Inquests can often prompt a wider discussion on serious issues, the most recent of these being mental health and suicide.
Editors actively ask and encourage reporters to speak to the family and friends of a person who is the subject of an inquest. Their contributions help us create a clearer picture of the person who died and also provides the opportunity to pay tribute to their loved one.
Often families do not wish to speak to the press and of course that decision has to be respected. However, as has been seen by many powerful media campaigns, the input of a person’s family and friends can make all the difference in helping to save others.
Without the attendance of the press at inquests questions will remain unanswered and lives will be lost.
Ms Ward said the child was born to the point of the chest at about 7.14pm. The court heard Zak-Ezra was taken to a neighbouring resuscitation room and an ambulance was called.
When doctors from elsewhere in the hospital arrived to assist Ms Ward said they requested equipment including a cannula, which was needed to aid the resuscitation of the child.
Ms Ward said she was only made aware the equipment was missing after the ambulance service requested it. “They had been removed,” she said.
Ms Saunders asked Ms Ward what checks are made to ensure the equipment is available. “There’s a daily check,” Ms Ward said.
The court heard Zak-Ezra was later transferred to the Royal Gwent Hospital for further care. He died at 4.10am on July 22.
Parents Adele Thomas and Stephen Carter share their last moments with baby Zak-Ezra Parents Adele Thomas and Stephen Carter share their last moments with baby Zak-Ezra (Image: Adele Thomas) Consultant in paediatric medicine Dr Andrew Bamber carried out a post-mortem examination on July 31. Giving oral evidence Dr Bamber said his investigation concluded a cause of death hypoxic ischemic brain damage with myocardial infarction caused by perinatal asphyxia.
Dr Bamber said the post-mortem revealed that the child had a lack of oxygen “on or around” the time of birth. He said he was unable to determine the cause of this without corroborating evidence from clinicians.
Summing up her findings, senior coroner Caroline Saunders said Ms Thomas was encouraged to stay home until she was 4cm dilated “in line with good practice guidelines”.
“Although Adele was clearly requiring reassurance and as a mother in her first pregnancy, there should have been more relaxation in these rigid rules,” she said.
Ms Saunders said there was evidence the foetal heart rate had been recorded in line with guidelines during the first stage of labour, but not in the second.
“At this stage the foetal heart rate should have been monitored every five minutes,” she said.
“However, no contemporaneous record was kept. I’m informed there should have been 13 recordings between that time and the time that Zak was born. Midwife Gibson records six recordings of foetal heart rate retrospectively. It is difficult to understand why these were not recorded at the time nor how midwife Gibson could accurately remember the time and rate after the birth.”
Ms Saunders said the monitoring of the child’s heart rate in the second stage of labour “fell well below the standards” expected of the birth centre. She said this represented a “gross failing in basic care”.
The coroner said she found that on the balance of probabilities no-one was resuscitating Zak-Ezra when the two doctors arrived in the resuscitation room, and “no-one voluntarily handed over what had happened”.
“It is not possible to say whether a different level of care or more frequent observations would have changed the outcome,” Ms Saunders said.
“It is clear that better observation may have alerted the midwives to an earlier problem, but I am aware that the treatment would have been to effect Zak’s birth earlier.”
Ms Saunders said there was a “missed opportunity” to effect a change in Zak-Ezra’s treatment as the observations were not carried out in the correct manner.
The coroner recorded a short narrative conclusion.
Ms Saunders said she had considered whether to order a regulation 28 report to prevent further deaths, but she said she was satisfied that steps had been taken to improve and monitor the care within the birthing centre.
Speaking after the inquest hearing, a spokesman for Aneurin Bevan University Health Board said: “Our condolences and deepest sympathy continue to be with Zak-Ezra’s parents and family.
“This matter was fully investigated by the health board and failings in care were identified. The investigation findings were shared openly with Zak-Ezra’s parents and the health board has sincerely apologised to them.
“We recognise however, that an apology will never make up for the pain and suffering they have experienced losing a child.
“The failings identified by the coroner focus on the individual practice of the two midwives, both of whom no longer work for the health board.
“However, we are determined to learn from this tragic incident to prevent this from happening again.”
> A young mother whose baby died following childbirth was turned away from hospital three times while in pain from labour
Yes, but it was free.
That’s the level of health care that the left wants for America.
There are 2 stories posted in a row, detailing the deficiencies of the Welsh medical system. Don’t seem to be linked, just random.
Exactly. The illegal aliens get OUR healthcare not NHS on OUR dimes thanks to Democrats.
Dreadful. RIP.
Medicare is NOT FREE there are premiums every month, AND you must also pay for a supplemental insurance!! I don’t know WHY in the hell the republicans don’t damn well get their messaging out there!!!
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