Gross failure led to newborn baby's death at Walsall MLU, coroner rules
Gross failure contributed to the death of baby boy who died hours after being born, a coroner has ruled.
Six vital failings during and after the birth of Zachary Johnson in Walsall could have contributed to his death, Black Country Coroner's Court heard.
Area coroner Joanne Lees said Zachary's heart rate had not been monitored every five minutes during stage two of Joanne Johnson's labour, as per NICE and Walsall Healthcare NHS Trust guidance.
Further failures included not ensuring a waterproof sonic aid was available to monitor Zachary's heart rate while Mrs Johnson was in a birthing pool.
More from the inquest:
- Inquest told of baby death after water birth heart monitor unavailable
- Inquest told of regrets over care after baby's death
- Baby's airways not checked duing hospital transfer, inquest told
Coroner Lees said Mrs Johnson should never have been allowed to give birth in pool in the first place once midwives at Walsall Manor Hospital's midwifery-led unit realised the correct equipment was not available.
But once in the pool, Mrs Johnson should also have been removed to ensure Zachary's heart rate could be measured, while the resuscitation procedure carried out on the baby on October 15, 2016, once he had been born, was also found to be incorrect and inadequate.
The inquest heard chest compressions had not been carried out at certain stages of the resuscitation process in the midwifery-led unit and there had been no airways management performed on Zachary while he was being transferred by ambulance to Walsall Manor Hospital.
Coroner Lees, speaking yesterday during the fourth and final day of the inquest, said: "I cannot think of anything more basic than monitoring the fetal heart rate.
"I also have no hesitation in saying Zachary was in a dependent position and the midwives had a duty of care."
Coroner Lees also pointed to a damning report by Professor Philip Steer, complied as part of a previous police investigation.
She it was clear that had Zachary had been born as little as 15 minutes earlier – and received "the appropriate resuscitation" – he would, on the balance of probability, have survived.
"Zachary died because of a lack of oxygen during birth. His death was contributed to by neglect," she said.
The inquest heard Zachary had not shown had any "pre-existing conditions" or had any "pre-disposing factors" before he died of intrapartum hypoxia on October 16, 2016, at 6.37am.
Addressing parents Joanne and Steven Johnson, of Lichfield Road, Willenhall, coroner Lees added: "I do not pretend for one second this will bring you closure, it's probably as raw as when it happened, but I want to thank you for the help you have given me.
"I offer my sincere condolences and wish you both the best for future."
The midwifery-led unit in Charles Street reopened last month after closing midway through 2017 due to staffing concerns.
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