Four-day-old baby died after 'gross' medical failures

A four-day-old baby died following "a gross failure to provide basic medical care" immediately before and during her birth, an inquest has concluded.

A post-mortem examination confirmed Etta Lili Stockwell-Parry suffered oxygen starvation during her birth at Ysbyty Gwynedd in Bangor in July 2023 - which lead to brain injuries.

The inquest found that midwives failed to spot warnings Etta's growth had become static on more than one occasion and she would "likely have survived" if she had been recognised as a high-risk case.

The coroner described it as "one of the most troubling cases" she had ever dealt with.

The hearing in Caernarfon heard Etta's growth measurements had become static when full-term pregnancy was reached - indicating growth of the baby had stopped, a condition known as foetal growth restriction.

Etta's mother, Laura Stockwell-Parry, told the inquest in a statement her daughter was "grey-coloured, limp and lifeless" at birth.

"I felt completely helpless and had no idea what was going on," she said.

"Our beautiful little girl was on a ventilator with lots of tubes."

Mrs Stockwell-Parry and her husband, Tristan, were told their daughter was having seizures, and would be transferred to a specialist unit at Arrowe Park Hospital in Wirral, north west England.

Etta's condition continued to deteriorate, with seizures becoming "uncontrollable" the court heard, so a decision was taken to stop treatment.

"We knew that she would not be able to survive," said Mrs Stockwell-Parry, adding "she passed away peacefully in my arms".

Community midwife Kiera Fitzgerald, who was caring for Mrs Stockwell-Parry at home, admitted she failed to recognise the baby's growth had stalled.

"I'm really sorry, I misjudged that," she said.

Ms Fitzgerald said the mother should have been referred for a scan on the baby but she was instead booked into hospital to have an induced birth.

The inquest heard the foetal growth issue was not spotted by at least two other midwives when Mrs Stockwell-Parry was admitted to the maternity unit.

Midwife Catrin Roberts said if she had spotted the growth charts, her approach would have been different.

"We thought she was a low risk. Static growth would make her a high risk," she said.

Errors were also made monitoring the unborn child's heart rate on the labour ward, with the mother's pulse being recorded rather than the infant's.

Coroner Kate Robertson told Etta's parents she would be writing to Betsi Cadwaladr University Health Board to express her concern at the investigation that had taken place into Etta's death.

"There has not been enough sharing of information, and I am not satisfied that all the findings of the investigation will be dissipated downwards to staff", she added.

Betsi Cadwaladr University Health Board has been approached for comment.