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The mother of a baby girl who died after just 33 days has welcomed a coroner's finding that "failings in the midwifery team" and "neglect" on the labour ward at Jersey's hospital contributed to her daughter's death.
A five-day inquest into Amelia Amber Sweetpea Clyde-Smith’s death concluded today, with Coroner Bridget Dolan highlighting several “shortcomings” in the care provided.
Amelia was born at Jersey’s General Hospital on 19 August 2018 and flown to Portsmouth immediately afterwards for emergency treatment.
She was flown back to the island where she received palliative care until her death on 21 September.
The Coroner said: “There had been a number of shortcomings in the management and delivery of the labour and unwanted delay in Amelia’s delivery.
“I find that these failings in the midwifery team were neglect.”
On the first day of the inquest, a midwife who treated the mother to be described how Amelia’s mother was in “distressing” and “horrible” pain shortly before she gave birth.
She also spoke of having been told not to speak of an incident that had occurred the night before. Two midwives giving evidence on the second day of the inquest spoke of a "tense" and "difficult" atmosphere resulting from the incident, as well as "culture issues" on the ward.
Experts, meanwhile, told the inquest that it was not right that Ms Clyde-Smith was advised that it was safe to wait 96 hours after her waters broke before inducing her, with accepted practice being to induce within 24 hours as infection risk grows by the day.
Another midwife who provided expert reports on Amelia's death explained how there was "no coordination" on the maternity ward the night she was born.
Baby's heart rate was not monitored properly
As the inquest entered its final day today, the coroner concluded that the causes of Amelia's death were bronchial pneumonia and the medical condition hypoxic-ischaemic encephalopathy – brain damage caused when not enough oxygen reaches a baby's brain before or shortly after birth.
This, the Coroner said, had been contributed to by neglect when on the labour ward.”
Among the failings was that cardiotocography, which is used in pregnancy to check the wellbeing of babies in the womb, was not monitored and reviewed properly.
She also said that the labour ward co-ordinator was unaware of Amelia’s mother’s progress, and that the consultant obstetrician should have been called to the ward promptly.
She added that failure to deliver Amelia sooner “left her exposed to a prolonged period of hypoxia”.
In a statement following the inquest, Amelia’s mother, Ewelina Clyde-Smith, said she was "grateful" for the Coroner's finding of neglect.
“Though the pain of losing Amelia remains, the fact that the circumstances of her death have been acknowledged gives us reassurance.”
Senior health officials previously apologised to Ewelina and Dominic Clyde-Smith after admitting Amelia’s death was “probably” avoidable, following an investigation by the Royal College of Obstetricians, which found there had been “missed opportunities”.
Chris Bown, Chief Officer of Health and Community Services, yesterday accepted there had been “serious shortcomings” in Amelia’s care and said: “Once more we would like to extend our deepest condolences to Amelia’s parents and to apologise unreservedly for these failings.
“We are deeply sorry for the pain and suffering that Amelia, her parents and her wider family went through.”
He added: “Amelia died almost six years ago, and the Government of Jersey accepted liability for her death some time ago.
“Since then we have made significant improvements to maternity care in Jersey, including the appointment of a new permanent Director of Midwifery with significant experience of senior midwifery leadership, additional consultants and midwives and more training in cardiotocography.
“We are constantly striving to improve maternity services in Jersey in order to make them as safe as possible for mothers and babies, but we are not complacent, and we continue to work closely with all the families who use our services to find ways of making further improvements.”
He added: “We will now carefully review the Coroner’s findings and will ensure that if any further action or learning is required this will be properly investigated and addressed.”
Day 1: Midwife asked not to mention incident the night before, baby inquest told
Day 2: Midwives tell baby inquest of "tense" atmosphere and "culture issues"
Day 3: Inducing after 24 hours "against recommendations", baby inquest told
Day 4: Baby who later died was born on ward with "no co-ordination"
Inquest opens into death of baby girl in hospital
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