Inquest into death of baby boy at Royal Derby Hospital opens

A midwife and a hospital trust apologised for the death of a baby boy at Royal Derby during the first day of a long-awaited inquest.

Tears and apologies defined the first day of a planned three-day inquest overseen by Sabyta Kaushal into the death of Ethan Blackwell, aged just 32 hours, on May 22, 2021.

Jodie and Ben Blackwell, aged 23 and 31, from Littleover, detailed how the heartbreak of Ethan’s death haunts them to this day and has significantly curbed their career aspirations and confidence levels.

They spoke about how baby Ethan did not cry when he was born and previously detailed he was never able to open his eyes, with only the ability to gasp for air.

The University Hospitals of Derby and Burton NHS Foundation Trust marked the opening of the inquest by saying they agree with recommendations from an independent report that there were a number of “missed opportunities” in the lead up to Ethan’s death,

It also acknowledged that Ethan should have been born seven hours earlier, at 5.30am instead of 12.30pm, in which case he would likely have been a fully healthy baby boy – and now be aged nearly three years old.

This is the second inquest into a baby death at Royal Derby Hospital in as many months with baby Zachary Taylor-Smith having been found last month to have died after 14 hours of life due to “gross failings” and “neglect” linked to antibiotics in November 2022.

The first day heard repeated references to a maternity unit which was understaffed and experiencing significant strain with not enough staff to provide care for the number of patients it had and the level of care they required.

Meanwhile, the hearing was also told how the neonatal team were not in the room with Ethan until the emergency buzzer was pulled, despite earlier concerns.

It first heard testimony from Dr Sophie Stenton, who carried out the post mortem on baby Ethan.

She determined that the leading cause of death was a “very severe hypoxic brain injury”, which is the deprivation of oxygen running to the brain for “several minutes”.

This caused Ethan to be born with almost all of his organs having already failed and major brain damage due to a “significant period of stress”

Dr Stenton also says there were signs of infection but she could not categorically say what the source of this infection was, due to a lack of sufficient samples.

The hearing was told that the emergency buzzer was pulled twice at around 3am and 5am to alert staff to issues relating to Ethan’s heart rate, with both incidents leading to discussions about potential emergency c-sections, but both were dismissed due to the rate reducing back within normal thresholds.

Signs of infection were present with Jodie looking “very unwell” at 5am but antibiotics were delayed by an hour by a doctor, the hearing was told, until blood cultures had been completed.

Danielle Bayley, the couple’s midwife for the majority of their labour, said she would challenge this if the same incident happened again because this is not the correct procedure for potential sepsis, dubbing it an “error”.

A pessary, a tablet on the end of a ribbon aimed at preparing the cervix for labour, fell out of Mrs Blackwell twice and was readministered.

However, on one of these occasions it fell into the toilet bowl onto used toilet paper but due to what has now been dubbed a “misunderstanding” it was deemed hygienic enough to be readministered.

Jodie told the hearing that the pessary was administered for a total of 30 hours, minus the two removals and reinsertions.

She said baby Ethan was born via the ventouse method, which involves a suction cup being attached to the head of the foetus and pulled.

Jodie said Ethan was covered in green slime and with his umbilical cord wrapped around his neck.

A tearful Mrs Blackwell said: “He did not cry.” Baby Ethan was taken to acute care for extensive support, with a doctor reportedly phoning other hospitals to ask for help and support, before telling the couple there was “no brain movement” and “there was nothing more that could be done”.

Baby Ethan was christened and the couple were asked if they wanted to remove his tubes.

This was done at 3.30pm on May 22 and Ethan died in Jodie’s arms six hours later.

Ben’s statement, read out by Miss Kaushal on his behalf, details that “the poor midwives were running around like headless chickens, it was so busy” claiming doctors had said the maternity unit was “understaffed”.

Mr Blackwell detailed: “I have flashbacks of all of this all of the time. There was blood, bile and green slime everywhere and Ethan was really poorly.

“When we saw him he was full of tubes and having seizures and convulsing… I dream about that all the time.

“A doctor told us there was too much damage and that he had called other hospitals. He looked exhausted.

“I breathed air into him to give him resuscitation to help him breathe and we had six hours with him.

“I feel I am a failure of a father and that I am to blame. I see the same scenes again and again. I just burst into tears and have breakdowns where I cry and scream.”

A written statement from Patti Paine, director of midwifery at UHDB, was read out at the hearing, in which she expressed her “sincere condolences for the unimaginable loss” Ben and Jodie have suffered.

She said the labour ward was “extremely busy” with 11 out of the 12 required midwives on shift with more complex births leading to deferrals elsewhere, based on need.

A further department had four out of the required seven midwives available.

She detailed that there was no evidence that the neonatal team were called prior to Ethan’s delivery, despite the “mechanical” delivery, which is more high risk, along with a “lack of clarity” about the presence or absence of doctors.

Ms Bailey who had been a qualified midwife for three months at the time of Ethan’s birth, following two years as a student, said she would not have signed off on the reinsertion of the pessary had she known it had fallen within the toilet bowl.

In relation to the “busy” ward she said: “I feel like I didn’t really know what was going on apart from in my room. I didn’t really come out of my room, I was with Jodie.”

She detailed there were complications with equipment meant to monitor the baby’s heart rate picking up the mother’s instead, and Ethan’s heart rate dropping rapidly on multiple occasions.

Ms Bayley says she intended to visit the Blackwells when she returned to work for her next shift, but was told she should not.

She told the hearing: “I just wanted to tell you both that I have wanted to speak to you for quite a long time. I really wish I would have just come that day. I am so sorry that you lost your little boy. Jodie you were amazing, you too Ben.”

A spokesperson for the University Hospitals of Derby and Burton NHS Foundation Trust said: “We are profoundly sorry for the shortcomings in care that Ethan and Jodie received in 2021 and our deepest condolences remain with their family.

“We are fully supporting the coroner’s enquiries for Ethan’s inquest to ensure his family have full answers to their questions and concerns, and it would be inappropriate for us to comment further at this time until the inquest proceedings have concluded.

“We remain absolutely dedicated to making the changes we have committed to so that we continue to improve the safety of care we provide for parents and babies at our hospitals.”

The trust says it has “fully accepted and acknowledged the failings in Ethan’s care” with an independent investigation having made recommendations which it claims it has acted on.

This will be detailed as part of the inquest, it said.

The inquest continues.