A BABY died after he suffered a brain haemorrhage during a failed forceps delivery, a coroner’s report reveals reports the BBC.
Frederick Terry also sustained a fractured skull and scalp laceration and during the procedure in Essex.
The coroner’s Prevention of Future Deaths Report said that, if not for those injuries, he would have survived.
Mid and South Essex Foundation Trust said it was “deeply sorry for the failings in his care”, in November 2019.
Frederick, known as Freddie, was eventually born via caesarean section, but was pronounced dead after 40 minutes of resuscitation attempts.
The report does not name the hospital maternity unit.
Basildon Hospital, which is part of the trust, was told to make “urgent improvements” earlier this year after its maternity ward was rated inadequate by the CQC.
Essex coroner Caroline Beasley-Murray’s report into Frederick’s death states: “The injuries imply an excessive degree of force in the application of the forceps and traction.”
Mrs Beasley-Murray said she decided to write the report prior to any full inquest.
However, the law states that investigations into a death must stop once it is concluded a baby is stillborn, so there will not be an inquest into Frederick’s death.
The medical cause of death was listed as hypovolemic shock caused by scalp and brain injuries from birth trauma.
In her report, Mrs Beasley-Murray said: “The evidence showed that baby Freddie’s very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby.”
She found 11 matters of concern including:
- Accuracy of record keeping
- Attempting a forceps delivery without recognising that the baby was in an occipito-posterior position
- A need for more training in how to talk to families and communications between staff in the delivery theatre
- Management of staffing on the maternity ward
- Availability and suitability of resuscitation equipment on the maternity ward
- Concerns about the engagement and induction of locum staff
- Need for a bleep in the neonatal unit
Diane Sarkar, chief nursing officer for Mid and South Essex NHS Foundation Trust, said: “Our thoughts and sympathies remain with Frederick’s family and loved ones, and we are deeply sorry for the failings in his care.
“We have been determined to learn from Frederick’s death, and we have strengthened our practices, introduced enhanced staff training, and embedded more robust guidelines to ensure that the quality of care at the Trust continues to improve.”