A CORONER has slammed the care given to a mum whose week-old baby died following a catalogue of hospital blunders as "nothing short of shocking".
Tiny Kaylan Coates suffered a fractured skull and brain bleed during a forceps delivery and tragically died from a hospital infection days later.
Staff at Queen’s Medical Centre, Nottingham, ignored pregnant 28-year-old Hayley Coates’ pleas for a Caesarean section and did not spot her baby's signs of distress, an inquest was told.
Despite being a high-risk patient, she was allocated a newly-qualified midwife and maternity ward staff failed to monitor her properly.
Now a coroner has ruled the tragedy, which left the young mother "broken and in shock", “could and should have been avoided” and neglect contributed to her baby’s death.
Kaylan was born on 23 March 2018 and during the delivery he suffered prolonged bradycardia, a slow heart rate, and associated hypoxia, a condition where the brain is starved of oxygen.
A pathologist said when Kaylan was finally delivered his skull was fractured by the use of forceps, leading to a bleed on the brain.
At the end of a five-day hearing, Nottinghamshire Assistant Coroner Laurinda Bower ruled that while infection was the primary cause of death, neglect and "serious, multiple failings in his care" had contributed to this.
The court was told that Miss Coates went into the hospital to be induced, but this progressed slowly.
Two days later, she was "struggling" and requested a Caesarean section.
Tragically doctors did nothing – an omission Ms Bower described as "nothing short of shocking".
Ms Bower said: "If Miss Coates' wishes had been properly explored, as they ought to have been, she would have maintained her wish for a Caesarean section delivery, and it would have been reasonable to have performed the same as a planned procedure that night before Kaylan's condition deteriorated.
"These failures led to a missed opportunity to have delivered Kaylan safely and would probably have avoided his death."
When Miss Coates, who was 24 at the time, was eventually taken into the labour suite, Kaylan's position was incorrectly identified and when forceps were used, his heart rate dropped dangerously.
BIRTH TRAGEDY
After his birth he was in a "poor condition" and he was placed on a ventilator.
Both doctors and midwives did not treat changes in the baby's heart rate with the seriousness it demanded.
Ms Bower found Kaylan's heart rate monitor reading was "miscategorised on multiple occasions" and the alarm was not raised properly.
She said this was "a really serious failure to provide a distressed baby with the care that he obviously required.
"It is accepted that this failure has more than minimally contributed to death, and therefore it is sufficient to underpin a finding of neglect."
Little Kaylan also caught a more serious infection, which was not picked up in time to be treated properly.
He contracted a hospital-acquired pseudomonas infection as a result of cross-infection from another patient on the unit.
Due to his already weakened condition, the infection took its toll and he died days later.
Speaking on behalf of Hayley, solicitor Emily Rose said: “This failure to properly and adequately explore Hayley’s wishes through a Caesarean section delivery was nothing short of shocking, and that this failure had a direct link to Kaylan’s death.”
Describing the moment her client saw her baby laying lifeless in an incubator she said it had left her “broken”.
She added: “For the first few months after Kaylan’s death, Hayley didn’t leave the house.
“The death of her baby boy has affected her mental health and up until the conclusion was delivered by the coroner, Hayley had no idea how her first-born baby had died.
“While the inquest won’t bring Kaylan back, it is hoped that his early, tragic and avoidable death will help prevent other parents from suffering the same devastating loss as Hayley and her family.”
Nottingham University Hospital Trust's medical director, Dr Keith Girling, said: "We are deeply sorry that this tragic incident happened and would like to offer our sincerest condolences to Miss Coates and her family.
"Our teams had to make some challenging decisions and regretfully missed opportunities on the day that Kaylan was born in March 2018.
"Our learning from this will inform part of the improvements we are making to our maternity services."
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