A baby died after maternity staff repeatedly missed chances to intervene to save his life, an official investigation has found.
Giles Cooper-Hall was just 16 hours old when he died after a catalogue of errors in the maternity care of his mother, Ruth Cooper-Hall, at Derriford hospital in Plymouth.
A Healthcare Safety Investigation Branch (HSIB) report into the incident, published on Tuesday, has exposed how inexperienced and overstretched staff failed to carry out proper checks, recognise there was an emergency or seek help from senior doctors until it was too late.
It comes just weeks after the independent Ockenden report into more than 1,800 cases revealed serious failings in the maternity care provided at Shrewsbury and Telford hospital NHS Trust.
HSIB’s new report highlighted how similar issues at University hospitals Plymouth NHS trust meant staff missed multiple opportunities to save Giles.
It revealed how Ruth Cooper-Hall, then aged 37, was not personally seen by a consultant when she went into labour in October last year, despite recommendations made in the interim Ockenden report published in December 2020.
The HSIB report also suggested Giles’ death could have been avoided if staff had known about the care plan for his mother’s labour. Instead, vital messages were not passed on, with the investigation finding this was likely to be because the staff responsible were “distracted” by other tasks.
Cooper-Hall and her wife, Allison Cooper-Hall, said the investigation had highlighted “the failures in care, missed opportunities and delay in recognition of the severity and urgency of the situation”.
“Our utter sadness and despair at losing Giles has been joined by anger and hurt as we now know that human error contributed to his death,” they said. “We should have come home with our baby – we will grieve for him for ever.”
Ruth Cooper-Hall first alerted staff at Derriford hospital that her baby wasn’t moving as much as normal when she was 41 weeks pregnant. But she was discharged and reassured the team was “not concerned at all”.
In fact, the HSIB investigation found staff had not carried out proper checks as the unit was “busy”.
A senior doctor’s advice that the baby’s heartbeat should be continuously monitored was not passed on to staff on the ground. The investigation found it was likely the “multiple tasks” being carried out by the responsible clinician had acted as a “source of distraction”.
Instead, the baby’s heart rate was checked only intermittently and without the recommended equipment, while new staff coming on duty repeatedly failed to check Cooper-Hall’s written records, so she was wrongly treated as a “routine” case, the investigation found.
“Had the full plan of care been handed over between the clinicians caring for the mother, there may have been a different outcome for the baby,” the report said.
Giles was delivered by forceps and had to be resuscitated for 20 minutes before his heartbeat was heard. But he was unable to breathe on his own, suffered blood loss and had brain damage from being starved of oxygen during labour. Later that day, his parents agreed he should begin palliative care and they were with him when he died at 8.30pm on 28 October.
Ruth Cooper-Hall, now 38, added: “We had concerns at the time with the care we received in the delivery suite, including the inexperience of staff, the lack of communication, the lack of confidence and the environment of fluster and panic, but we left Derriford having been given the impression that what happened to Giles was just a tragic accident.
“We thought it had all happened in the last 10 minutes of labour, but the report reveals such a larger timeframe of errors, missed opportunities and delay.”
Peter Walsh, chief executive of the patient safety charity Action against Medical Accidents, said: “This is yet another tragic and avoidable loss of a baby … Too few staff and poor communication between overstretched staff. Maternity care is in a bad way and must be a top priority for more resources and improvement.”
A spokesperson for University hospitals Plymouth NHS trust said: “All the safety recommendations stemming from the investigation will be fully implemented as part of our commitment to foster a culture of learning, development and improvement within the maternity setting.
“Most importantly, we would like to thank the Cooper-Halls. May we again reiterate our most sincere condolences upon the sad loss of their son, Giles. The pain and distress they have experienced is immeasurable.”