Death of baby boy at Royal Derby Hospital "contributed to by neglect"
A coroner has ruled the death of a baby boy at Royal Derby Hospital just 14 hours after his birth was “contributed to by neglect”.
A coroner has ruled the death of a baby boy at Royal Derby Hospital just 14 hours after his birth was “contributed to by neglect”.
The University Hospitals of Derby and Burton NHS Foundation has fully accepted the findings of baby Zachary Taylor-Smith’s inquest and said it is “deeply sorry” for its failures in his care before he died in November 2022 following breathing difficulties.
Baby Zachary died from a life-threatening condition called Group B Strep. The condition is a type of infection and is common for pregnant women but can be very serious for newborn babies. However, the inquest heard how Zachary’s parents Hannah and Tim Taylor-Smith had not been made aware of it until Zachary had passed away.
The final moments of baby Zachary’s inquest saw Coroner Susan Evans conclude there had been “gross” and “total and complete failures” in relation to basic care and stated there had been several “missed opportunities” by staff which could have prevented Zachary’s death.
Coroner Evans said hospital staff should have provided antibiotics to Hannah during labour and Zachary while he was alive. If they had done so Zachary may have survived, she said. She added staff should have responded sooner to Zachary’s deteriorated health on the morning of November 17, 2022, when risk factors were in play and should have carried out immediate reviews on his condition at key points during his short life. The coroner said she would file a report for the prevention of future deaths.
On the opening day of the inquest on Monday, March 4, the hospital trust in charge of Royal Derby Hospital admitted a series of failures in Zachary’s care. Evidence was then heard by staff members and medical professors who were treating Zach on the day he was born and died.
An emotional Hannah and Tim delivered a statement outside Chesterfield Coroner’s Court after the coroner delivered her conclusion today (Tuesday, March 12). They said the treatment they and Zachary received by the hospital trust was “appalling” and are calling for a nationwide review in maternity services to ensure other parents do not experience the grief they have had to endure in the past 18 months.
The heartbroken couple claimed the hospital trust has issued more ways of learning from the tragedy than the number of hours Zachary ended up living for (14).
They said: “Zachary was perfect in every way; we fell in love with him the moment we laid eyes on him. We were so excited for our other children to meet him, to bring him home knowing that we had the final piece of our puzzle, and he was so loved by all.
“Nothing could have prepared us for what we were to witness, there is no pain like watching your child pass away and being totally helpless to stop it, with the added reality of breaking each of your children’s hearts as they come to understand their sibling is dead. We all struggle to navigate this new life without our child/baby brother, we all miss him so much it physically hurts.
“Zachary was not a learning opportunity, nor should he have been a sacrifice made for the greater good. He was a child who was failed by the very people who should have protected, cared for and treated him.
“Fourteen is the amount of hours our son lived for. Sixteen is the amount of safety action points the trust has identified prior to the inquest. 1,600 is the amount of issues that the trust had already identified that needed change.
“What is particularly hard to come to terms with is the catalogue of errors made in my and Zachary’s care. Not one individual recognised that antibiotics should have been given to me during my labour, one simple action that the trust agreed would have made a difference. Midwives also did not recognise that he was deteriorating, which has been accepted was fundamental to their job.”
Hospital bosses have said they are “determined” to learn the lessons from Zachary’s death and said one key change brought in was midwives now attending neonatal handovers to make sure any outstanding reviews are identified to all relevant colleagues.
They said all staff have received a learning briefing regarding guidance on prophylactic antibiotics in pre-term labour and the hospital’s bleep system has been reviewed and improved. New systems are in place which include actions in place should parents raise health concerns after their child’s birth.
Garry Marsh, executive chief nurse at University Hospitals of Derby and Burton NHS Foundation Trust (UHDB), said: “The loss of a baby is devastating and we are sincerely and deeply sorry for the failings in Zachary’s care, which we fully accept.
“We should have provided antibiotics and responded differently to changes in Zachary’s condition and we have been determined to put changes in place, including now using a best-practice tool which helps to better identify any deterioration in newborn babies, has clearer processes for staff to escalate, and means any parental concerns are also immediately shared with the neonatal team.
“Our teams now signpost women directly to information on Strep B, and whilst screening for Strep B is not routinely offered in the UK under national guidance, a month after Zachary’s death we proactively joined and supported a national Strep B research trial.”