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October 1st 2021

Inquests

Coroner raises concerns as inquest finds baby boy who was never registered as having lived did show signs of life after birth at 22 weeks

Emma Stone

Emma Stone

Solicitor, Clinical Negligence

Coroner raises concerns as inquest finds baby boy who was never registered as having lived did show signs of life after birth at 22 weeks

The family of a baby boy who was never officially registered as having lived have thanked a Coroner for agreeing to hold an inquest after it ruled he did show signs of life after being born at just 22 weeks.

The family of a baby boy who was never officially registered as having lived have thanked a Coroner for agreeing to hold an inquest after it ruled he did show signs of life after being born at just 22 weeks.

The parents, who have asked not to be named, have also thanked Hudgell Solicitors for ‘ensuring their baby boy will be remembered for the right reasons’, as his birth and death will now be officially registered.

Due to miscommunication between the ambulance staff and Blackpool Victoria Hospital, it was recorded that the mother had suffered a miscarriage, meaning there was no post mortem and the baby’s birth and death were not registered.

An inquest, which was held on the request of the family following legal representations, determined that their baby had shown signs of life after his birth, with the cause of death extreme prematurity and therefore natural causes.

Coroner Alan Wilson said he would write two Regulation 28 letters to the North West Ambulance Service and Blackpool Teaching Hospitals NHS Foundation Trust highlighting possible dangers arising from the case.

Regulation 28 letters and reports are made by Coroners when they hear evidence which gives rise to ‘a concern that circumstances creating a risk of other deaths will occur, or will continue to exist in the future’.

They set out concerns and request that action should be taken, with the organisation in receipt having 56 days to provide a response, including details of actions taken to prevent future deaths.

Mr Wilson said he would be highlighting the miscommunication between the ambulance and hospital about the baby boy’s condition when he was born, which led to his death being incorrectly registered, and a mistake made by the ambulance dispatcher which caused the incident to be incorrectly marked as relating to only one patient, rather than mother and baby.

The inquest had heard how the 26-year-old mother gave birth prematurely in her bedroom at 22 weeks and four days gestation, just a few hours after doctors at the hospital had sent her home, on September 8, 2017.

She was advised she was suffering from a water infection and sent her home with antibiotics and painkillers, without a speculum examination being carried out.

Giving evidence, the baby’s parents told how he was making ‘gurgling noises’ and his ‘arms and legs were moving’ after being born.

Paramedics who attended observed signs of ‘agonal breathing’, a natural reflex which happens when a person is not able to draw in enough oxygen to survive, and CPR was administered at the home and on the journey to hospital.

The inquest heard that, despite an ambulance crew report noting that the baby boy had shown signs of life when he was born, as a result of miscommunication between ambulance and hospital staff, it was recorded as a miscarriage and so no post-mortem examination was carried out.

Medical experts told the Coroner that it was ‘highly likely’ that the baby boy would have died even if he had been born in hospital, and he concluded that death was by natural causes, with the cause being extreme prematurity.

Solicitor Emma Stone, of medical negligence law firm Hudgell Solicitors, represented the family at inquest alongside Elizabeth Fox, of Sergeants’ Inn Chambers.

She said a civil case is being pursued alleging negligence in the treatment when discharging the mother home, as she had shown several red flag signs of premature labour and was known to be at risk of miscarriage due to two previous C-section births and other health factors.

She said: “This was a very traumatic experience for our client and her family, and of course something which will impact on their lives forever.

“The loss of a baby is always a very difficult time, whatever the circumstances of that loss.  However, for our client to be sent home from hospital, give birth at home and see her baby boy struggling for life was heart-breaking. This was then further compounded by being told her baby was not being recognised as having lived, meaning there was no post-mortem, and no registration of his birth or death.

“It was for that reason that the family pursued an Inquest and they are grateful to the Coroner for recording that their baby boy had shown signs of life after birth, and that he died of natural causes due to the prematurity of his birth.”

The boy’s mother said: “For the past four years we have had to battle for our son’s birth, and short life, to be recognised. We heard him gurgling after he was born and his father and paramedics tried their best to help his breathing until he arrived at hospital.

“To have no recognition of your baby’s life due to a communication mix up is heart-breaking. Nothing we could do could bring him back, but we simply couldn’t allow him to have no place officially in history. We are hugely grateful to the Coroner for his findings. It means so much to us as a family.”

The boy’s father added: “This situation has been very difficult me and for the family. Our baby boy will always be in our hearts, but knowing that justice has now been done, has finally meant our baby boy can be remembered for the right reasons. I am very grateful to our solicitors, the Coroner and everyone else involved for all their hard work, and will forever be grateful.”

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