Kaylan Coates inquest: Coroner finds 'shocking' mistakes

Some of the care given to a mother whose baby died at a Nottingham hospital was "nothing short of shocking", an inquest has heard.

Staff failed to consult Hayley Coates properly at the Queen's Medical Centre in 2018 and did not spot her baby's signs of distress, a hearing was told.

Kaylan Coates suffered serious injuries during a forceps delivery and died from a hospital infection a week later.

The coroner said Kaylan's death "could and should have been avoided".

Assistant Coroner Laurinda Bower returned a narrative verdict saying while the infection was the primary cause of death, neglect and "serious, multiple failings in his care" had contributed to this.

After a normal pregnancy, Hayley Coates, from Broxtowe, went into the Queen's Medical Centre on 20 March 2018 to be induced but this progressed slowly.

Two days later, she was noted as "struggling" and the coroner found she requested a Caesarean section but this was not escalated to doctors, 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."

As the night progressed 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," Ms Bower said.

When Ms Coates was taken into the labour suite Kaylan's position was incorrectly identified and when forceps were used, his heartrate dropped dangerously.

After his birth he was in a "poor condition" and scans showed Kaylan had suffered a fractured skull, associated bleeding and brain damage due to lack of oxygen.

He was placed on a ventilator and treated with antibiotics.

After initially responding to treatment he caught a more serious infection, which was not picked up in time to be treated properly and Kaylan died on 30 March.

Solicitor Emily Rose said Ms Coates was "broken and in shock".

"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," she said.

In December 2020, a CQC report was published, which found that maternity care at the trust was inadequate.

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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