A baby died after a C-section was delayed due to a ‘failure to communicate’ between the staff and a consultant who was working from home.
Daisy McCoy’s mother had gone to the hospital reporting reduced and unusual foetal movement, but an inquest heard her pleas were not acted on swiftly enough.
Staff at Yeovil Maternity Unit in Somerset failed to escalate the situation, and confusion between medics meant Daisy’s emergency caesarean was delayed.
The delay was caused by ‘failure to communicate’ between staff, including the consultant who was working remotely.
By the time Daisy was born on February 9, 2022, she had already suffered a brain injury.
The inquest found that the brain injury was already present when Daisy’s mother attended the maternity unit, and an earlier delivery would not have impacted her chances of survival.
The maternity unit has since shut temporarily due to ‘high staff sickness’, with the local MP blaming a ‘toxic work culture’ for driving medics away.
Deborah Archer, area coroner for Devon, Plymouth and Torbay, has now warned there is a ‘gap’ in their policy regarding consultants or midwives attending when understaffing risks patient safety.
Staff at Yeovil Maternity Unit, pictured, in Somerset failed to escalate the situation, and confusion between medics meant Daisy’s emergency caesarean was delayed
The inquest heard that Daisy was born via Caesarean section at the hospital on February 9, 2022.
Her mother had reported abnormal foetal movement, but there was a delay in the operation because of ‘failure to communicate’ between staff and a lack of training around the significance of this presentation.
A scan showed that Daisy had suffered a brain injury due to a lack of oxygen or blood flow.
The interruption to blood flow was ‘potentially due to a problem with the umbilical cord or placenta’, a report by the coroner said.
Her parents were left on their own for an hour with no explanation of how serious the injury was.
After she was born, she was rushed to Southmead Hospital in Bristol, before later being transferred to a hospice in Barnstaple, Devon. She died on February 22, 2022.
The consultant working remotely did not ‘fully consider’ if she should come in to assist because she was unaware of staffing problems on the ward as the unit’s guidance did not include asking one to attend if there was an issue outside of the staff’s experience or skill set.
Only the registrar, a middle-ranking hospital doctor undergoing training as a specialist, knew that the abnormal scan required a call to the consultant within 30 minutes, but she did not phone in either leading to a further delay in the procedure.
Staff did not check the criteria for a normal heartbeat and therefore did not escalate the results of the test.
The consultant told the inquest that if she had been aware of the outcome, she would have come onto the ward at that point.
Ms Archer recorded a narrative conclusion that the 13-day-old had died due to an interruption in blood flow to the brain, which caused ‘significant damage’ and perinatal asphyxia before her delivery.
In May this year, Yeovil Maternity Unit closed temporarily due to ‘high staff sickness’ and it is due to re-open November.
Deborah Archer, pictured, area coroner for Devon, Plymouth and Torbay, has now warned there is a ‘gap’ in their policy regarding consultants or midwives attending when understaffing risks patient safety
During a House of Commons session in June, Yeovil MP Adam Dance told the chamber absences were caused partly by ‘a lack of support, and toxic work culture, and bullying from management.’
It was found that the brain injury had already happened when the mother arrived at the maternity unit and an earlier delivery would not have impacted her chances of survival.
However, Ms Archer said the hearing had revealed a ‘number of concerns’ about procedures at the maternity unit.
In a Prevention of Future Deaths report, she warned that further deaths may occur given the lack of training on abnormal foetal movements, the absence of policies on escalation of emergencies, and a gap in the policy on consultants attending when the ward is understaffed.
The unnamed consultant said that if she had been made aware of the seriousness of the situation overnight, she would have come in.
Her report has been sent to the associate medical director of Musgrove Park in Taunton, the other hospital run by Somerset NHS Foundation Trust, and where many mothers from the closed Yeovil unit have been sent.
They have until September 30 to respond.
This article was originally published by a www.dailymail.co.uk . Read the Original article here. .