Safety changes mean 'Giles has a legacy' but mum's vow 'we need a national maternity inquiry'
'A truly tragic case', the words today from the Plymouth coroner as she outlined a series of failures ahead of the death of a 13 hour old baby
Last updated 2nd Feb 2024
A Narrative verdict was today recorded following the death of a baby at Plymouth's Derriford Hospital, with Giles Huw Cooper-Hall's mothers now calling for a 'National Inquiry into Maternity Safety'.
Assistant Coroner Louise Wiltshire called it a 'tragic case' as she outlined 'missed opportunities in the care of the baby, who died after around 13 hours - but stressed she was was not clear whether the overall outcome would have changed.
Concerns highlighted included not monitoring potential warning signs, problems with the handover between staff and not declaring an 'emergency' quickly enough.
Mums Allison and Ruth today sat in tears at times as a report, following Giles' death in October 2021, highlighted potential delays in the way staff responded and problems with information sharing at the maternity service during handovers - which is currently rated as 'requires improvement' by the Care Quality Commission.
The mothers are backed by campaign group Maternity Safety Alliance, who have called what happened 'catastrophic failures'. The Alliance wrote to the health secretary in October 2023 calling for a national inquiry and warning there's been a rise in the number of children and mothers dying between 2020 and 2023.
A 'quality and safety of maternity care' research briefing was published for England in December and the UK Parliament also looked at the safety of maternity services in England in 2021.
The Government response can be found here
What happened to Giles Huw Cooper-Hall?
Concerns grew after Mrs Hall, then 37, reported 'reduced baby movements' and was induced at 41-weeks-plus-six days in October 2021.
Giles was born with a birth weight of 3.15kg and at first showed no signs of life. A resuscitation process started and Giles' heart rate was first heard 20 minutes later but he sadly died after 13 hours following efforts to save him.
Dr Alexander Taylor, a consultant obstetrician and gynaecologist, based at Derriford, who wrote Giles' care plan was asked about the falling heart rate recorded for Giles - which fell from 130bpm to 110-112bpm within an hour.
He told the inquest that, at a potentially crucial stage, staff did not have a chance to review notes which may have a sparked an element of 'risk progression' or 'something changing' with the falling heart rate.
He said he didn't believe it 'just suddenly happened' that the heart rate fell to the 60s-bpm - and 'best' monitoring available may have helped as 'we could have known or predicted the status of Giles in that timeframe'.
When asked if different actions could have resulted in a different outcome, Dr Taylor replied: "I can't say it would have been different but I do agree it may have been different."
He described what happened as a 'hideous situation', and was in 'disbelief of who the patient is' when he found out - as Ruth was not a pregnancy he had been overly concerned about that day. He also confirmed, at that time, he did not know his care plan 'hadn't been followed'.
Dr Alex Allwood, a consultant at University Hospitals Plymouth NHS Trust, was asked if an earlier delivery of potentially 14 minutes could have made a difference. He replied: "I am reasonably confident it would not have done."
The inquest was told Dr Allwood had since visited the mothers at their home - and was thanked publicly on their behalf by their legal team for the time he has spent with them.
The coroner was told about a previous 'oversight' in monitoring of the baby's growth trajectory - but it was unclear what differences more information could have resulted in. The evidence presented at the inquest also suggested that one risk assessment 'missed some key risk factors' and some monitoring 'did not happen' - leading to a later recommendation for the trust about 'pink amniotic fluid'.
Nicola Pusey, who was the maternity investigations team leader for South West at the Healthcare Safety Investigation Branch (HSIB), answered questions for the coroner about their 2022 report.
She outlined the report which found: "HSIB considers that a loss of situational awareness, (brought about by a focus on a new method of calculating the baby’s heart rate), and a lack of understanding of the mother’s risk factors (due to information held by the clinician at the time), led to the emergency call bell not being activated when the baby’s heart rate could not be heard, which meant that senior involvement was delayed."
The HSIB found that different actions 'may have resulted in the baby being born earlier' but also stressed: "Escalation may have led to the baby’s birth being expedited sooner and it is not possible to know if this may have altered the outcome for the baby."
The report made a recommendation on the trust to 'ensure that staff recognise when a foetal heart rate cannot be heard or there is a suspected bradycardia (slower than normal heart rate) that immediate escalation occurs and an emergency is declared'.
The findings from the HSIB also recorded how 'a member of the obstetric team also spoke with the mothers during this time, explaining who the staff were resuscitating their baby, “letting them know what was going on.”
It added: "A clinician that the mother knew from a previous episode of care also sat with them and held the mother’s hand, which they both found 'so, so helpful'."
The HSIB made five recommendations in light of the case, which included 'the trust to support staff to complete a risk assessment, which includes review of the records, at every point of handover of care to enable recognition of a mother’s risk status'.
It also called for 'the trust to ensure that staff recognise when a foetal heart rate cannot be heard or there is a suspected bradycardia that immediate escalation occurs and an emergency is declared'.
How is the maternity department currently rated?
The maternity service at Plymouth's Derriford Hospital is currently rated as 'requires improvement' by the Care Quality Commission
In March 2023, Carolyn Jenkinson, the CQC deputy director of secondary and specialist healthcare, said: “At times, the quality and safety of maternity care at Derriford Hospital fell short of standards women and babies have a right to expect."
She continued: "We also found training targets weren’t being met, and the trust must address this to ensure people’s safety" but did note 'staff were doing their best to provide good care and keep people safe'.
The HSIB, which conducted the report, is funded by the Department of Health and Social Care, and has an 'ambition to bring a new perspective and develop meaningful and influential recommendations to support improvements in patient safety'.
What has the NHS said?
The inquest was given an update on work that has taken place since the 2022 review 'as there was certainly learning to be done for many individuals', according to the director or nursing for the trust Sue Wilkins - who added 'staff don't come into work to cause harm'.
The coroner heard a detailed update on the new systems and internal procedural changes now in place - and examples of how different medical emergency situations are now responded to.
The raft of changes included improved 'handovers' as staff shifts crossover.
A previous statement from University Hospitals Plymouth NHS Trust said: "Since the advent of the Healthcare Safety Investigation Branch (HSIB) in 2018, the Maternity Department at University Hospitals Plymouth has welcomed the opportunity to participate in this national programme of high quality, independent and family focused reviews into maternity care.
"We would like to extend our gratitude to the investigating team for their support of both the family and the staff involved. All the safety recommendations stemming from the investigation will be fully implemented as part of our commitment to foster a culture of learning, development and improvement within the maternity setting.
"Most importantly, we would like to thank the Cooper-Hall’s. We have been honoured to have the opportunity to be involved with the family and maintain an open dialogue whilst the investigation has progressed; explaining how we will develop services reflective of the HSIB findings. May we again reiterate our most sincere condolences upon the sad loss of their son, Giles. The pain and distress they have experienced is immeasurable."