The two-day inquest into the circumstances surrounding the death of seven-hour old Casey Garrett, who died on 11th September 2014 at Bedford Hospital (Bedford Hospitals NHS Trust), has found that there were a series of missed opportunities which led to his death.
The Senior Coroner, Mr Thomas Osborne delivering a narrative verdict yesterday, said: “Casey Garrett was born on 10 September 2014. Prior to his delivery at Bedford Hospital there were a number of failures to recognise that his condition was deteriorating and there was a failure to escalate the levels of care so as to expedite his delivery. These failures resulted in a lost opportunity to deliver him earlier and avoid his death. He died on 11 September 2015 at 07:10 from perinatal asphyxia.”
The Coroner held a full and detailed inquiry examining the wider issues that resulted in Casey’s death. The inquest examined the standard of care provided on 10th September 2014 at Bedford Hospital including the midwifery team’s ability to interpret foetal heart rates and training of midwives to enable babies to be delivered safely.
As a result he will be visiting the chief executive of the hospital to ensure safe procedures are being adhered to. He will also be writing to the body responsible for training student midwives to consider whether Bedford Hospital is an appropriate place to train students in the light of the series of failings the inquest identified.
Mr. Osborne also expressed deep concern that women at the hospital were not informed that they could choose to be electronically monitored, as currently the choice is only given once the woman’s labour deviates from the norm.
Casey’s mother, Mrs Anna Garrett was admitted to Bedford Hospital on 10th September 2014 for the birth of her first child. Casey was born later that evening but was not breathing. He was resuscitated and transferred to the Neonatal Unit, but died seven hours later in his parents’ arms, after being christened by a priest.
The Trust carried out an internal inquiry identifying several failings including breaches of its own guidelines, in particular failure by the midwives to call for medical assistance when there was, amongst other things, lack of progress in the second stage of labour and failure to interpret the baby’s heart rate properly.
Mr Dean & Mrs Anna Garrett attended the inquest and said: “We feel very let down by the staff at Bedford Hospital who we had placed the utmost trust in. However, we feel that Casey’s death has been a pivot for change and agree with the coroner that his short life has and will make a huge difference to the safety of patients. We could not have wished for a more open inquiry.”
“We are both so very grateful for the short time we spent with Casey. He was the most beautiful baby boy and he changed our lives forever. It is true that the smallest footprints have the power to leave an everlasting imprint on this earth, only Casey left his deepest footprints in our hearts.”
Julie Say, medical negligence lawyer at Hodge Jones & Allen and Sebastian Naughton, Counsel of Serjeants’ Inn Chambers represented the family. Julie Say says: “This has been one of the most open inquests that I have attended and one that has been a force for change with all interested parties working toward improving patient safety. Anna and Dean have felt that all the concerns that have troubled them have been aired in public”
The Coroner found that:
1. A CTG commenced when Anna originally attended should have been continued for 20-30 minutes because the CTG trace was not reassuring;
2. When Anna was admitted, she was in the active second stage of labour, although this was not realised by the midwife attending her;
3. Information on the midwife co-ordinator’s notice board as to when Anna’s second stage of labour started was incorrect and misleading. It recorded that the second stage had started at 9pm rather than at 7:19 pm; this resulted in the co-ordinator not doing the checks that she would normally do;
4. There was a failure to carry out intermittent monitoring of Casey’s heart beat in line with Trust and national guidelines which state that the heart rate ought to have been checked every five minutes;
5. By 10pm at the latest there should have been a review by an obstetrician, or senior midwife;
6. There was a failure to properly interpret the CTG trace which had been started shortly after 10pm, which had either recorded the maternal pulse, or if it was monitoring the foetal heart rate was “grossly abnormal”;
7. There was a lack of communication which led to a failure to call for medical staff to attend;
8. Had medical staff been alerted when they should have been, Casey would have been delivered by around 10:30 pm;
9. Had Casey been delivered 20-30 minutes earlier than he was (i.e. after 10:41-10:51 pm) he would have survived.
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