The cries for help from a pregnant woman who was heavily bleeding at a Nottinghamshire hospital went unanswered by midwives for almost 40 minutes before the death of her baby, an inquest has found. Theo Bradley died at one-day-old after being born with a severe brain injury at King's Mill Hospital in Sutton-in-Ashfield in September last year.
An inquest into his death, which concluded on Friday, July 5, found delays in assessing mum Amelia Bradley contributed to his death. A coroner said the baby would likely have survived had it not been for "gross failures" in care.
Ms Bradley and her partner Luke Sherwood, from Kirkby-in-Ashfield, previously told the inquest they heard midwives talk about how many Haribo sweets they had eaten while waiting to be seen. Sherwood Forest Hospitals (SFH) said it had "failed to live up to the high standards of care" and said "appropriate action" had been taken.
Ms Bradley said Theo's death is "something we’ll never get over". The 26-year-old, who has now applied to start a midwifery degree, said: "We’d been looking forward to becoming a family and to have that ripped away from us in such a cruel way was nothing short of traumatic.
“To this day, I still wake up and hope it’s all been a nightmare and then it hits me and I’m completely floored by the grief. Knowing that our baby boy will never even celebrate his first birthday is so difficult to come to terms with.
"All we can hope for now is that no other families have to go through the heartbreak we have. I wouldn’t wish it on anyone.” Ms Bradley, who was 41 weeks pregnant with no previous concerns, rang the hospital at around 12.30am on September 15 when she began to bleed heavily.
She was advised to come to the Sherwood Birthing Unit by triage midwife Rachel Smedley, however the inquest found the assessment taken over the phone was "inadequate". Assistant coroner Elizabeth Didcock said Ms Smedley did not recognise that Ms Bradley had had a major haemorrhage and also did not inform other midwives that she was coming in and bleeding.
Ms Bradley arrived at the unit at 1.05am being pushed in a wheelchair by Mr Sherwood, with it "obvious she was in pain".
The inquest was told she was not seen by a midwife for another 37 minutes, which went against hospital guidelines that require triage within 15 minutes of arrival. Ms Bradley's mum, Tammy, called "two or three times" for help from the room but midwife Glenys Wood, who was sat at the desk about four metres away, told the coroner she did not hear her.
Ms Didcock said she had not been able to establish how they were not heard. The assessment was finally undertaken at 1.42am by which time Theo had a "profound and persisting" slow heart rate.
He was born by emergency Caesarean and was transferred to Nottingham City Hospital's neonatal unit, where the decision was made to stop his treatment. Ms Didcock said there were "many missed opportunities" to save Theo, including a failure to establish the major haemorrhage over the phone and a failure to triage Ms Bradley sooner.
"There were issues of lack of reception cover that night, and overall poor coordination, perhaps a lack of situational awareness, issues of professionalism, all adding to the delay in assessment," she added.
Ruling neglect contributed to Theo’s death, she said: "The omissions of care in this case are serious, very serious, and in my judgment they are gross failures." Ms Didcock said they were likely "broader systemic and worrying issues", particularly in relation to a lack of understanding of the seriousness of vaginal bleeding, and the need to act quickly.
"It is highly likely to be a cultural issue within the midwifery team." She also said it was "unfortunate" that the trust decided to not make training on the new triage system, implemented in May, mandatory. The trust has since changed this.
Phil Bolton, chief nurse at SFH, said: “I would like to take this opportunity to reiterate our unreserved apology to the family of baby Theo at what we know has been and continues to be an incredibly difficult time for them.
"Only the individuals involved that night truly know why Theo and his family did not receive the care they needed and deserved, and I am clear that we have failed to live up to the high standards of care that our communities are right to expect from their local hospitals.
“We have gone through a thorough HR process following Theo’s death to take decisive action and appropriate actions have been taken. We will take the coroner’s findings on board and will continue working with Theo’s family to do all we can to prevent this from happening again.”
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