Jessop Wing: Coroner fears "future deaths" at Sheffield maternity unit unless improvements are made
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Assistant Coroner Tanyka Rawden said that tiny Henry Jackson would have survived had his mother Siobhan Weir, aged 22, been diagnosed with pancreatitis earlier.
And she has also raised concerns of “future deaths” unless improvements are made at the unit.
Siobhan was 33 weeks pregnant with twins when was rushed into the Jessops – part of Sheffield Teaching Hospitals NHS Foundation Trust – in June last year after she was vomiting and had concerns for her babies.
Tragically Harry was delivered stillborn and moments later Henry was born in a poor condition, not breathing and without a heartbeat.
Medics were able to resuscitate Henry, but he died after spending six days in intensive care.
Blood results that would have indicated that his mum was suffering from pancreatitis, a potentially deadly condition, were also not checked until the following morning.
Delivering a narrative conclusion at the end of a two-day inquest into Henry's death Mrs Rawden said the baby would have survived if tests had been taken on Ms Weir earlier.
She said: “There were missed opportunities to recognise that Henry's mother was seriously deteriorating.
“Had it been recognised that Henry's mother was deteriorating, tests would have been done and it would have been discovered earlier that Henry's mother was suffering from pancreatitis.
“Had that been discovered, a Caesarean would have been carried out sooner and Henry would have survived.”
Mrs Rawden said she had 'significant concerns' about the evidence she had heard during the inquest.
She had been told that Ms Weir was sent home twice from the hospital after medics assumed she had hyperemesis, a condition causing nausea and vomiting.
At one stage, the mum even felt like she'd “pulled a muscle” after throwing up for days on end but was continually sent back home as her condition seemed to improve.
And at a critical time, on the evening of June 16, a midwife hadn't completed regular checks on her during the night.
Mrs Rawden added: “I do have a concern there is a risk of future deaths in the future if there are not changes on that unit.”
However, she said the hospital trust that runs the maternity wing has made 'significant changes' to its working practices.
As such, she deferred writing a prevention of future deaths report until she had given the Trust a chance to prove it had implemented and audited those changes.
She gave the Trust a deadline of September 30 to produce that evidence.
She added: “I expect to see those changes I've heard about implemented and audited or I will be writing a report to prevent future deaths.”
Addressing Ms Weir and her partner, Luke Jackson, Mrs Rawden said: “I can't imagine what the last 13 months have been like for you.
“What happened to you on that day, nobody should go through. It shouldn't have happened to you or anybody else.
“The evidence before me shows me that without a doubt, those caring for you should have spoken to you about CTGs.
“They should have spoke to you and talked you through that and they didn't. This was not your fault.
“I am so sorry your boys are not here and sharing their lives with you.”
Speaking after the inquest, Ms Weir, a care home worker, said: “We were delighted when we found out we were going to become parents.
“We felt incredibly blessed and even more so when we found out we were expecting twins.
“When I was in hospital I was poorly but at no point did I feel that the severity of the situation was explained to me.
“When I went into hospital for the third time I never expected what would happen.
“More than a year on we still can't really believe what happened and how both Harry and Henry didn't make it.
“It's impossible to put into words how difficult it remains trying to come to terms with how Henry and Harry didn't make it.
“It's difficult not to think how things could be different and both the boys could be at home growing up and starting to cause mischief.
“Nothing will ever fill the void in our lives. I don't think we'll ever get over losing Harry and Henry and we will continue to think about them every single day.
“They will always be a part of our family and we'll never stop loving them.
“I hope that by speaking out others who find themselves in a similar situation don't have to suffer alone. Help and support is available.”
Rosie Charlton, the expert medical negligence lawyer at law Irwin Mitchell, which is representing the family, said after the hearing: “While nothing will ever make up for the pain Siobhan and Luke continue to face we're pleased that we've at least been able to help provide them with some of the answers they deserve.
“The inquest and the Trust's own investigation have highlighted worrying areas in the care Siobhan received.
“While we welcome the Hospital Trust's openness during the inquest and pledge to make changes, it's now vital that these are introduced and upheld at all times to improve maternity safety.”
Dr Jennifer Hill, Medical Director, Sheffield Teaching Hospitals NHS Foundation Trust, said: “The heartbreak that Siobhan, Luke and their wider family have suffered by losing two precious babies is something which will stay with them forever and I realise that an apology will never be enough to alleviate that loss.
“We fully acknowledge that whilst our staff work hard to provide good care for women and their babies, during Siobhan’s admission on 16th June 2021 we failed to detect the deterioration in her condition quickly enough.
“We have taken what happened very seriously and conducted a full review of how and why it happened. We have already made initial changes to our processes and staff training and are continuing to embed further changes to limit the chances of anything similar happening again. We will also be sharing the learning widely with all the teams involved.”