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Baby who later died was born on ward with "no co-ordination"

Baby who later died was born on ward with

Friday 12 April 2024

Baby who later died was born on ward with "no co-ordination"

Friday 12 April 2024

There "wasn’t any co-ordination" on the maternity ward the night of the birth of a girl who later died, after the midwife-in-charge took on the care of another woman in labour, an inquest has heard.

Amelia Amber Sweetpea Clyde-Smith was born in the Jersey General Hospital in August 2018 and flown to Portsmouth for emergency treatment.

She returned to Jersey and died in September, aged 33 days.

On the first day of the inquest, a midwife said that Amelia’s mother was in “distressing” and “horrible” pain shortly before she gave birth.

The inquest heard yesterday that on the night of Amelia’s birth, labour ward co-ordinator Catherine Richardson had taken on the care of a woman who was in labour while midwives had been given an extended break.

Midwife Anne Carvalho, who provided expert reports on Amelia’s death, told the inquest that the co-ordinator should not be taking on such work unless no other solution could be found.

The labour ward co-ordinator is often the most senior midwife on the whole maternity unit, particularly on a night shift, she explained.

As such, they needed to be available to tend to emergencies and advise colleagues.

The coroner commented: “It’s a simple point that a labour ward co-ordinator needs to be co-ordinating things, and there wasn’t any co-ordination here.”

Patrick Armstrong, Medical Director for Health and Community Services, said yesterday that “lessons would be learned” from the death and stressed that some changes had already been made.

Senior health officials previously apologised to parents Dominic and Ewelina Clyde-Smith, saying that Amelia’s death was “probably avoidable”, after an investigation by the Royal College of Obstetricians and Gynaecologists found there had been “missed opportunities”.

On Wednesday, the inquest heard that Amelia’s parents had been given “falsely reassuring” advice that, after Mrs Clyde-Smith’s waters had broken, it was safe to wait another 96 hours before the pregnancy might need to be induced.

The advice from the UK’s National Institute for Clinical and Health Excellence was that birth should be induced within 24 hours.

Asked by coroner Bridget Dolan whether maternity services in Jersey would now provide NICE advice, Mr Armstrong replied: “The simple answer is yes. Most of our health professionals trained in the UK and are members of bodies in the UK. They follow NICE guidelines.”

The inquest had previously heard that there had been a “difficult” atmosphere on the labour ward on the night of the Amelia’s birth.

The inquest continues today and the coroner is expected to deliver her verdict this afternoon.


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

Inquest opens into death of baby girl in hospital

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