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Inquest told of baby death after water birth heart monitor unavailable

A baby who died hours after being born did not have his heart regularly monitored due to a lack of equipment, an inquest has heard.

The Walsall Midwifery-Led Unit, in Charles Street, Walsall

Mother Joanne Johnson had decided to have a water birth at Walsall Manor Hospital’s Midwifery-Led Unit on October 15, 2016.

However, Black Country Coroner’s Court heard yesterday that there were no water-proof heart monitoring units on the day, which meant midwife Junie Drummond had been unable to check the baby had a healthy heart rate.

The inquest also heard an on-call support worker had called in sick on the same day, and both midwives Mrs Drummond and Patricia Cronin had been unable to use a resuscitator machine, once Zachary had been born, because the oxygen was not working.

Mrs Johnson, aged 34, of Lichfield Street, Willenhall, who had previously given birth to her now six-year-old daughter, Ellie, arrived at the midwife-led unit, having requested a water birth.

She had asked for the same procedure for her daughter but following complications had been transferred to Walsall Manor Hospital, where she had given birth to a healthy girl

The inquest heard that on October 15, 2016, she had progressed well through stage one of the labour process at which point the midwife had started to fill up the birthing pool.

Area coroner Joanne Lees asked Mrs Drummond: “Did you have any concerns about Joanne using the birthing pool without a waterproof monitoring aid?

Mrs Drummond replied: “No, because she was fit and healthy, and at first was able to lift herself up, bringing her abdomen out of the water, so I could check it.”

Problems arose, the inquest heard, during stage two of the labour as Mrs Johnson was no longer able to lift herself up due the intensity and frequency of her contractions.

“Joanne went into the second phase about 8.30pm. The contractions were stronger and she was getting more distressed,” said Mrs Drummond.

“I tried to monitor the baby’s heart but couldn’t because she was holding on to side of the pool.”

Mrs Drummond said because the contractions were strong, and with Mrs Johnson ready to push, she had expected a quick birth.

But more than half an hour later, Zachary was born and placed on Mrs Johnson’s shoulder.

The inquest was told that a baby's heart should be monitored every 15 minutes in stage one of the labour and every five minutes in stage two.

Once it was realised the newborn was not breathing he was taken to the resuscitator ­– and when it was discovered there was no oxygen the two midwives began trying to resuscitate him using the ‘bag and mask’ technique, along with chest compressions, while the paramedics were called.

Zachary was eventually rushed to Walsall Manor Hospital but died of acute severe hypoxemia after his parents agreed to turn off his life-support machine due to severe brain damage.

The three-day inquest continues.

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