Jessop Wing Sheffield: Coroner highlights 'neglect' at maternity unit during inquest into baby's death

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A baby boy’s life could have been saved if a Sheffield maternity ward had acted on warning signs and performed an emergency Caesarean section, a coroner has ruled.

Barney Bear Hutton was just five-days-old when he passed away at the Jessop Wing in Sheffield on June 16, 2021. He was born at just 30 weeks after his mother, Stephanie, was brought to the maternity unit with abdominal pain and bleeding.

But an inquest has ruled his death due to serious brain damage during his delivery could have been avoided if doctors had acted on warning signs and given him an emergency Caesarean in 30 minutes – rather than waiting up to two hours.

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Assistant coroner Stephen Eccleston’s narrative verdict was the ward did not act after spotting a dangerous anomaly in the baby’s heart rate. Despite the issue being “repeatedly underlined” in briefing notes, Jessop Wing registrars did not raise the alarm to get Stephanie into surgery.

A coroner has ruled that a Sheffield maternity ward's failure to act quickly on warning signs that could have saved a baby's life amounted to neglect.A coroner has ruled that a Sheffield maternity ward's failure to act quickly on warning signs that could have saved a baby's life amounted to neglect.
A coroner has ruled that a Sheffield maternity ward's failure to act quickly on warning signs that could have saved a baby's life amounted to neglect.

Mr Eccleston said: “The hospital failed to properly monitor, interpret and act on a heart rate trace which indicated Barney should be delivered by category one emergency Caesarean section. Had such action been taken in a timely way, then it’s likely that Barney would have lived. This failure amounts to neglect in Barney’s care.”

A spokesperson for Sheffield Teaching Hospital NHS Trust told the inquest the ward was “deeply sorry” for the failure.

Afterwards, Dr Jennifer Hill, the Trust’s Medical Director, said: “The loss that Barney’s family have suffered is something which will stay with them forever and I realise that saying sorry will never be enough to alleviate that loss. We fully acknowledged that we failed to provide the standard of care we would normally expect and that this resulted in a tragic delay in Barney being delivered.

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“We have taken what happened very seriously and quickly made changes to limit the chances of anything similar happening again. This has included implementing a process called ‘fresh eyes’ which means that another clinician reviews information and decision making to provide a second check that the right actions are being taken. This is just one of a number of measures that have been taken since June 2021 when Barney was delivered.”

During the two-day hearing, Barney’s mother tearfully asked why the ward did not act of the warning signs.

“All my scans were normal – he was perfectly healthy,” said Stephanie at the hearing. “So why, between me getting there and him coming out, did I wait two hours?

“How could anybody have waited that long? They should have got him out in 30 minutes.”

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The court heard how the worryingly slow heartbeat was spotted as the team monitored the mum and baby’s heartbeat – known as a CTG – and it was even “underlined repeatedly” in briefing notes as ‘pathological’, meaning it was a serious concern.

But the issue wasn’t treated seriously enough by registrars on Jessop Wing. The surgeon who delivered the baby, Dr Ranjan Sen, told the inquest he was not made aware of this critical fact when he arrived on the ward – otherwise, he would have taken the mum to surgery immediately.

The inquest also heard how, because the team had not escalated how serious the issue was, they chose to wait for a Covid-19 test and a platelets test to come back to see if it was safe to anaesthetise Stephanie. However, the court heard both tests came back safe 10 minutes before Dr Sen even arrived on the ward.

“Why did everyone wait when my tests had come back already?” the grieving mother asked the doctor.

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“In that case, I think it is quite right to say the Caesarean section should have happened earlier,” the surgeon replied.

It comes after Jessop Wing was slammed for failings in a report earlier this year. After being rated ‘inadequate’ by the CQC in March 2021, inspectors were in disbelief to find it had “deteriorated” even further in a second visit in October 2021.

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