A day-old girl died after “systemic” failings at a troubled maternity unit and would probably have survived had her mother been moved 12 miles to a specialist centre, a coroner has concluded.
There were a series of mistakes in the care of Nelly Webb and missed opportunities to save her after her premature birth at the Royal Glamorgan hospital in south Wales, an inquest in Pontypridd heard.
Nelly was born with respiratory distress syndrome and weighed 1.13kg (2lb 8oz), but south Wales assistant coroner Sarah-Jane Richards said she “would have likely survived” if her mother, Jessica Webb, had been transferred to Cardiff to give birth.
Concluding there had been “systemic failures”, the coroner said: “The statement of the baby’s mother made damning reading of a service in disarray. There was insufficient attention to the tests, medication and treatment from a team which appeared fragmented with multiple doctors and nurses providing different care plans.
“She was not considered for transfer. There was no discussions between obstetrics and neonatology about the imminent birth and the likely need for intubation, ventilation and specialist care.
“The on-call consultant should have come to the hospital at the time of intubating Nelly and been cot-side to oversee the procedure. There was inadequate supervision of junior doctors at the time and poor follow-up the next day.”
The coroner said a delay in inserting a chest drain was a “missed opportunity”. When the drain was inserted it went into the wrong place.
In written evidence, Webb, 31, said she was taken to see her baby after giving birth by caesarean section on New Year’s Day 2019. She said: “I was so happy to see my baby after a difficult pregnancy.”
But Nelly deteriorated suddenly and the couple watched as doctors tried to resuscitate her. “We stood by as they administered drugs – it was horrific to watch. We felt so out of control, we couldn’t believe what we were seeing,” said Webb.
She said initially they were led to believe that her death was “an unfortunate and unavoidable consequence of her prematurity” and were “utterly shocked” to discover the care Nelly received had fallen short.
Outside court, Diane Rostron, birth injuries solicitor, said: “Jessica and Rikki [Nelly’s father] lost their first born little girl in circumstances that could have been avoided. They have been left deeply traumatised by their loss. We hope this finding leads to key learnings. The family will now pursue a medical negligence claim against the hospital.”
Rostron is working on a total of 18 birth injury-related claims against the Royal Glamorgan hospital and its sister site, the Prince Charles hospital in Merthyr Tydfil – and another 14 against other Welsh boards.
Maternity services at Royal Glamorgan hospital in Llantrisant were put into special measures four months after Nelly’s death, when dozens of concerning cases were identified. It is now out of special measures.
Paul Mears, the chief executive of Cwm Taf Morgannwg University health board, apologised to Nelly’s family.
He said: “Since 2019, we have made significant changes to maternity and neonatal services in our health board. This work has been guided by a major improvement programme, overseen by an independent maternity services oversight panel commissioned by Welsh government.
“Our neonatal units are now located at Prince Charles and Princess of Wales [in Bridgend] hospitals, each with a dedicated consultant and a specialist neonatologist, increasing the level of senior clinical leadership on our units every day of the week.”