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Five day old baby died after delivery was delayed due to being a low priority inquest hears

Five day old baby died after delivery was delayed due to being a low priority inquest hears

Frederick "Freddie" Rowan Whewell died from brain damage

Gloucestershire Live

A lawyer representing the family of a baby boy who died at just five days old say it is vital that Gloucestershire Royal Hospital reviews its procedures following his death.

An inquest this week heard that Frederick "Freddie" Rowan Whewell's mother, Jay, was admitted to hospital in labour at around 5am on May 24, 2020. She was reviewed by two different obstetricians - one at 09.17am and the other at 1.25pm.

The latter diagnosed obstructed labour which resulted in a clinical plan being put into operation - for the administration of oxytocin to be stopped, and to stop pushing. It was also decided to take Mrs Whewell to theatre for a trial instrumental delivery or caesarian section.

However, two other mothers also needed urgent medical intervention - and because the attending clinicians did not believe it was possible to open a second operating theatre to deliver Freddie - the obstetric team was not available until 3.15pm.

A caesarean section was performed at 3.49pm and Freddie was delivered five minutes later. He was transferred to Bristol Neonatal Intensive Care Unit where he died five days later.

A post-mortem examination, conducted by Dr Andrew Bamber, a consultant paediatrician based at the North Bristol NHS Trust, found that Freddie died from traumatic and hypoxic injury to the brain consistent with the history of a difficult birth delivery with impaction of the skull in the pelvis, requiring manual manipulation of the head.

Following Freddie's death, the Healthcare Safety Investigation Branch (HSIB) launched an inquiry. In its 83-page report which involved the work of a panel of 12 investigators, the HSIB concluded that obstructed labour should have been suspected when Mrs Whewell was reviewed by Dr Maggie Arlidge at 9.17am.

It also found that the delay in going to theatre may have contributed to Freddie's head becoming deeply impacted.

In recording a narrative conclusion, coroner Roland Wooderson explained that it was deemed unsafe to proceed with instrumental delivery following an examination in theatre.

"Caesarean section birth was complicated by placental incision and an impacted fetal head requiring additional manoeuvres to dis-impact Freddie's head," he said.

"HSIB found that there was a delay in retrieving emergency neonatal blood as theatre staff were uncertain about where this was kept and that Freddie would have likely responded to resuscitation sooner if blood had been given earlier."

Since Freddie's death, the HSIB has made some recommendations to Gloucestershire Royal NHS Foundation Trust, which includes ensuring midwives receive the appropriate training and that proper systems are in place.

Mr Wooderson ruled out making a Prevent Further Deaths (PFD) report and was satisfied that the Trust is on course to follow through with all of the recommendations.

Statement from family lawyer

In a statement released after the inquest, Emma Rush, the expert medical negligence lawyer at Irwin Mitchell representing Freddie's parents, Jay and Andrew Whewell, said: “Understandably Jay and Andrew have been left devastated by Freddie’s death and the particularly harrowing events surrounding his birth.

“Jay and Andrew have had a number of concerns about what happened and sadly the inquest has heard worrying evidence as to the care the family received. While nothing can make up for their ordeal we’re pleased that we’ve at least been able to provide the family with the answers they deserve.

“It’s now vital that the Trust reviews its procedures and training for staff to improve patient care for others.

“We’ll continue to support Jay and Andrew at this distressing time to help them access the specialist support they need to try and come to terms with Freddie’s death the best they can.”

'A fighter until the end'

Jay and Andrew Whewell also made a statement and paid tribute to their son. "We were overjoyed when we found we were expecting Freddie and were so excited that he would be part of our family," they said.

“It’s difficult to put into the words the emotion of how what should have been one of the happiest moments of our lives turned to such despair.

“Freddie was such a fighter right until the end. While he was taken from us far too soon we feel so blessed that he was our boy.

“We knew the inquest and listening to the evidence regarding what happened to Freddie was going to be incredibly difficult but it was something we had to do in order to have answers to our many questions as well as honour his memory.

“Nothing will ever make up for the pain of losing Freddie but we just hope that by speaking out we can raise awareness of what we’ve been through to help other families."

What the hospital trust said
In a statement, Mark Pietroni, Director for Safety and Medical Director at Gloucestershire Hospitals NHS Foundation Trust, said: “The circumstances surrounding the death of baby Freddie are tragic and we would like to extend our heartfelt sympathies to the family.

“We are committed to learning all we can from this. The coroner was satisfied with the progress that the Trust has made in implementing the recommendations of the Healthcare Safety inspection Board, including the provision of a second emergency theatre team. We will ensure that they are embedded in our practice for the future."

Following Freddie's death, the Frederick Rowan Whewell Star Tribute Fund was set up, which has so far raised over £9,000.

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