A coroner has criticized a maternity ward for the deficiencies in care that she claims caused a newborn baby delivered through emergency caesarean section to die.
Little Henry Jackson would have lived, according to assistant coroner Tanyka Samantha Rawden, if his mother Siobhan Weir, 22, had had an early diagnosis of pancreatitis.
When Ms. Weir was brought into Sheffield Teaching Hospital’s Jessop Maternity Wing in June of last year, she was 33 weeks pregnant, vomiting, and worried about the heartbeats of Henry and his unborn twin Harry.
Tragically, Henry was born without a heartbeat and without breathing, while Harry tragically died during delivery.
Henry was revived by medical personnel, but after six days in intensive care, he passed away.
The cause of death was listed as a serious brain injury brought on by oxygen deprivation and induced by maternal pancreatitis, according to evidence presented at Sheffield Coroner’s Court.
Additionally, blood test results that would have revealed she had pancreatitis, a potentially fatal illness, were not examined until the morning.
Henry would have survived, according to Mrs. Rawden, who gave a narrative verdict at the conclusion of a two-day inquest into his death, if tests had been performed on Ms. Weir sooner.
There were opportunities missed to notice that Henry’s mother was badly deteriorating, the woman claimed.
A fluid balance chart was performed 11 hours after admission, according to the report.
The time between CTGs was 14 hours and 45 minutes.
‘Tests would have been performed and Henry’s mother’s pancreatitis would have been identified earlier had it been recognized that she was deteriorating.
“Henry would have survived if that had been found, a caesarean would have been performed sooner.”
Regarding the testimony she had heard during the inquest, Mrs. Rawden stated that she had “serious concerns.”
She had been informed that Ms. Weir had been twice discharged from the hospital due to what the staff believed to be hyperemesis, a disorder that causes nausea and vomiting.
The mother had been throwing up for days on end and at one point even felt like she’d “pulled a muscle,” but she kept getting sent home as her condition seemed to get better.
Additionally, a midwife hadn’t performed routine checks on her during the night of June 16 at a crucial period.
If there are no modifications made to that unit, Mrs. Rawden continued, “I do have a concern there is a potential of future deaths in the future.”
However, she said that the hospital trust in charge of the maternity ward has changed its working procedures “significantly.”
She waited to draft a report on the prevention of further deaths until the trust could demonstrate that the modifications had been made and audited.
She gave the trust until September 30 to present that proof.
I anticipate those improvements being implemented and audited, she continued, “or I will be submitting a report to prevent future deaths.”
I can’t image what the past 13 months have been like for you, Mrs. Rawden said to Ms. Weir and her companion, Luke Jackson.
“Nobody should have to go through what happened to you that day.” It wasn’t supposed to happen to you or anyone else.
“The information before me convinces me beyond a shadow of a doubt that those looking after you ought to have discussed CTGs with you.
They ought to have discussed that with you and spoken to you about it, but they didn’t. You aren’t to blame for this.
I’m sorry your guys aren’t here to enjoy their lives with you with you.
Ms. Weir, a care facility employee, stated after the inquest: “We were thrilled when we found out we were going to become parents.”
“When we learned we were having twins, it made us feel even more grateful.
“I was ill at the hospital, but at no point did I feel that the seriousness of the situation was explained to me,” the patient said.
“I never anticipated what would happen when I entered the hospital for the third time.”
“More than a year later, we still find it hard to comprehend what transpired and how both Harry and Henry perished.
It’s tough to put into words how difficult it still is to accept how Henry and Harry did not survive.
It’s tough to avoid considering how things might have turned out differently and how both boys might have grown up at home and started getting into trouble.
The emptiness in our lives will never be filled by anything.
We won’t ever get over losing Harry and Henry, and we’ll always remember them in our thoughts.
They are a part of our family now and forever, and we will always love them.
By speaking out, I wish to spare the suffering of others who are in a similar situation.
There is help and support available.
“While nothing will ever be able to make up for the pain Siobhan and Luke continue to experience, we’re pleased that we’ve at least been able to help provide them with some of the answers they deserve,” said Rosie Charlton, the expert medical negligence attorney at Irwin Mitchell who is representing the family after the hearing.
“Worrisome elements in the care Siobhan received have been revealed by the inquest and the Trust’s own investigation.”
While we appreciate the Hospital Trust’s candor throughout the inquest and its commitment to change, it is now crucial that these improvements be implemented and upheld constantly to improve maternity safety.