Inquest into tragic deaths of premature twins

Jack and Spencer Dolan died in Liverpool having been moved there following their early births at just 25 weeks at Walsall Manor Hospital.

Liverpool Women's Hospital was the closest specialist premature ward with spaces available when they were born on May 31.

But an inquest heard how staff had to manually call up and check each specialist unit to see if there was space - something senior coroner Zafar Siddique said was not the best use of their time.

Mr Siddique said the babies' deaths was down to complications arising form their early birth and there is no suggestion the 90-mile journey caused any problems.

But he said: "I want to raise a concern that it is not the best use of time for a medic to be calling around hospitals."

Dr Caroline Holland, consultant radiologist at Walsall Manor, who was reviewing the case for the trust, said: "It is not an efficient way, it took 45 minutes. It is national practice to find a level three specialist cot for extremely premature babies. The neo natal unit was full to capacity, this happens frequently, every few weeks."

Walsall Manor is not equipped to deal with premature babies born under 28 weeks and the family were told they would be transferred to another hospital.

Attempts to locate spaces in a level three neo natal specialist ward had to be conducted manually as a computer system which records the number of spaces in units across the country is only updated Monday- Friday between 9-5pm.

The babies were taken to Liverpool separately with Spencer having to wait until Jack had arrived in Liverpool and the transfer could return to collect him.

Once in Liverpool, the condition of each of the boys deteriorated and they died aged five and six days old.

The inquest at Smethwick Council House found that Jack died from a brain haemorrhage and complications caused by the extreme prematurity of his birth. Spencer also died from premature birth complications and a brain injury.

Their parents Victoria and Christopher Dolan, from Barn Owl Drive in Pelsall attended the inquest.

Mr Dolan said: "We knew they would have to fight for their lives. We knew it would be a battle for them but we were just hopeful that they would pull through."

Mr Siddique said: "My conclusion for both children is that the cause of their deaths was complications arising from prematurity at birth. It is an absolute tragedy to lose your babies but I'd like to thank you for your dignity during this inquest."