Ystrad Fawr Hospital: Baby died two days after being born

There was a "gross failure in basic care" which led to a baby being starved of oxygen during birth, a coroner said.

Zak Ezra Carter died at the Royal Gwent Hospital, Newport, two days after being born in July 2018 at Ystrad Fawr Hospital in Caerphilly county.

Gwent coroner Caroline Saunders said the monitoring of Zak and his mother Adele Thomas fell "well below the standards expected".

She said she was reassured the health board had taken steps to improve care.

Ms Thomas told the Newport hearing she felt "scared" and staff "didn't care" when she arrived to give birth on 20 July 2018.

In a statement to the inquest she described being turned away from the centre after going into labour on three occasions, before being admitted on the fourth.

On one occasion, she said she was told she might benefit from a walk around a nearby Tesco store.

Ms Thomas said she was initially offered paracetamol as pain relief at the midwife-led centre.

She described "a lot of arguing between nurses", one of whom was "bolshie and rude and rough handled me", adding the midwives "did not appear to be in any rush".

When Zak was born, he was described as being "white and pale" and without a heartbeat. He did not cry and was taken away to a room for resuscitation.

Zak was transferred to the Royal Gwent Hospital where he died two days later.

The inquest heard Anthony Ridge Blackwell, an operating department practitioner from elsewhere in the hospital, was called to the birthing centre while paramedics were on their way.

In a statement, he said he was initially unable to access the unit because the doors were locked.

He said the "lack of urgency was very apparent" among staff, who he described as "clearly upset and hugging each other".

Mr Blackwell said he had to search for equipment among "very limited resources" before providing basic life support to Zak until paramedics arrived with more equipment.

Midwife Theresa Ward told the coroner she came into the birthing room to assist midwife Lisa Gibson, who has been off work with stress since.

She said she had previously raised concerns about Ms Gibson's work with her superiors, and so on this occasion went in earlier than she normally would to help with the birth.

In a statement, Ms Gibson said she had retrospectively recorded observations taken during labour.

Ms Ward said the chart used to keep a record of the observations was not in the birthing room when she went in and "didn't think to get it".

She said she did not "go in and take over" but suggested Ms Thomas changed her position to help with the birth.

At one point, Ms Ward said she could not hear a heartbeat but Ms Gibson said she could faintly hear one.

When she checked again five minutes later and still could not hear a heartbeat, Ms Ward said she told Ms Gibson to "get the baby out" by carrying out an episiotomy.

The coroner heard Ms Gibson spent time looking for the equipment and words were exchanged about the urgency.

When she was asked why she did not take over, Ms Ward said she did not know why she did not.

Before the episiotomy was carried out, the inquest heard Zak's head and shoulders had emerged.

Ms Ward said once he was born she carried Zak to the resuscitation area and attempted to revive him until two men she did not know arrived and took over.

She said they did not have some of the equipment the men asked for and there were no drugs for babies on the birthing unit, only for mothers.

Dr David Phillips, a consultant anaesthetist, was asked to go to the birthing unit and said he found internal doors were locked and had received "vague instructions" about how to find Zak.

Dr Phillips told the coroner he did not recall "any active resuscitation" when he arrived, and Zak was grey and lifeless so he and Mr Blackwell immediately started CPR.

He said he was not given any handover or description of the circumstances of the birth, adding "communication was quite difficult".

The two members of staff seemed to be too emotional to help - one or both were in tears, he said.

Dr Phillips said some of the equipment he would have expected was not available until paramedics arrived.

He said a combination of CPR, adrenaline, defibrillation and intubation led to Zak's condition improving enough to be transferred to the Royal Gwent Hospital.

Julia Sanders, a professor of clinical nursing and midwifery with Cardiff and Vale University Health Board, carried out an independent investigation into what happened.

Prof Sanders told the coroner there was nothing to indicate the birthing centre at Ystrad Fawr Hospital was an inappropriate place for Ms Thomas to give birth.

During the first stage of labour, Prof Sanders said "everything was progressing at a normal healthy rate and the fetal heart rate was recorded as completely normal".

But she said it was "highly unusual" for the heart rate to not be documented contemporaneously, and the midwives had not been able to explain why they had not done so.

Louise Taylor, a consultant midwife at Aneurin Bevan University Health Board, told the hearing an action plan had been implemented to address many of the concerns raised by the hearing and investigation.

Recording a narrative conclusion, Ms Saunders said the monitoring of Ms Thomas and her baby had "fallen well below the standards expected", leading to a "gross failure in basic care" of them in the later stages of labour.

The coroner said she was satisfied that when Dr Phillips arrived in the birthing unit "no-one was resuscitating Zak and no-one voluntarily handed over what had happened".

However, she said she was reassured Aneurin Bevan University health board had taken steps to improve and monitor the care provided in the future.

Speaking after the hearing, Zak's parents said they were disappointed with the conclusion.

Ms Thomas, who has since gone on to have a baby girl, said she had felt helpless during Zak's birth.

She said she was "angry", "bitter" and sad following the "dark few months of the immediate aftermath".

She said the new baby had "definitely saved us".

Ms Thomas added: "We think of Zak every single day... we'll never forget him."

A spokesman for Aneurin Bevan University Health Board said: "Our condolences and deepest sympathy continue to be with Zak's parents and family.

"This matter was fully investigated by the health Board and failings in care were identified. The investigation findings were shared openly with Zak's parents and the health board has sincerely apologised to them.

"We recognise however, that an apology will never make up for the pain and suffering they have experienced losing a child."

It said neither of the two midwives still worked for the health board but added it was "determined to learn from this tragic incident to prevent this from happening again".

If you have been affected by the issues raised in this news story, visit BBC Action Line for information on the support available to you.