Doctor admits lapse in standards at baby-death hospital

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The Independent Online

Standards of care on a busy maternity ward where a newborn baby died were not as high as they should have been, an inquest heard today.

Baby Ebony McCall was born by Caesarean section at Milton Keynes General Hospital in May.

The little girl, who was full term, only had a faint heartbeat and died just over half an hour later.

An inquest at Milton Keynes Civic Centre has heard her mother Amanda McCall, who was 17 at the time, suffered medical conditions including cardiac disease.

She was admitted to hospital on May 8 with stomach pains, and despite requesting birth by Caesarean section was not given one.

Miss McCall, now 18, naturally entered labour that night but the baby's heartbeat became erratic, necessitating the emergency Caesarean she had wanted in the first place.

Ebony was born pale and floppy at 3.21am on May 9, and had an erratic heartbeat. Despite attempts to revive her, she was pronounced dead at 3.54pm.

She had suffered brain damage due to a lack of oxygen, caused by ingesting her own faeces, a pathologist has told the inquest.

Today hospital staff admitted the standard of care received by the teenage mother had not been as high as they should have been.

Miss McCall's consultant Anthony Stock told the inquest: "The care in this case should have been consultant-led and right at the outset I am happy to acknowledge that the care did not come up to a standard that I would have expected normally for a patient booked in my name."

He said Miss McCall was considered "low risk" in cardiac terms but when she came into hospital with stomach pain, would have been "high risk".

He said: "She is high risk for two reasons, the first is the one that has been highlighted, the fact that she has cardiac disease but she is also high risk because she is at term and has pain at the moment for which we have no diagnosis."

The inquest heard a call was made to Mr Stock the night Amanda came into hospital but he did not pick up a voicemail until the following week.

Deputy Coroner for Milton Keynes Thomas Osborne asked Mr Stock if a lack of midwives and beds had put babies and mothers at risk.

Last year Mr Osborne reported the hospital to the Department of Health after the death of baby Romy Feast, who was born by Caesarean section at the hospital in 2007 but died after her cardiotocography (CTG) was misinterpreted.

Following his referral, a Healthcare Commission investigation was launched.

Today Mr Osborne said the 2008 report found many recommendations had not been met.

He said the report said there appeared to be a high degree of pressure on bed occupancy and more than one midwife had expressed concerns that mothers and their babies were being discharged early, leading to a higher-than-average readmission rate.

The inquest heard the average readmission rate at Milton Keynes General was 12.8%, compared to a national average of 4.1%.

Mr Osborne also said recommendations about bed numbers had not been met.

Mr Stock said: "The action plans that have arisen from inquiries have been proceeding and are still proceeding.

"I agree entirely that in an ideal world we would have greater accommodation.

"Milton Keynes is not unique. We have a scenario where we have not just got an increasing birth rate but increasing complexity.

"The number of other medical conditions such as cardiac disease, sickle cell disease, HIV, every factor that increases workload has gone up by more than the 10-15% increase in ante-natal and delivery activity.

"We have not managed to keep up despite a lot of hard work on the part of the midwifery managers.

"I think everyone acknowledges within the department that we do need to have higher staffing levels and more space."

Today midwife Ruth Evans said shifts could be "overwhelming" at times.

Head of midwifery services Elizabeth Hunter told the inquest standards of care had not been met the night Miss McCall gave birth.

She said: "I fully acknowledge that with the complexity of the circumstances that night the systems did not support us in ensuring the standard of care and safety that we would have wished.

"I believe that the staff on duty that night acted and performed with all credible presence and to the best of their ability."

The inquest heard funding was available to employ more midwives, but the hospital struggled to recruit.

Mr Osborne said: "If you are a midwife at the start of your career, Milton Keynes from the level of activity is not an attractive place to work, with the stress that they are under."

This morning, also at Milton Keynes Civic Centre, Mr Osborne opened an inquest into the death of another baby born at Milton Keynes General Hospital.

Alexander Broughton was born on December 2 but died the following day after being transferred to the John Radcliffe Hospital.

The inquest heard his mother had gone to hospital with no "foetal movement" but was scanned and reassured.

At 8pm that night she went into labour and Alexander was born at 11pm but was not breathing.

A crash team was called, he started suffering fits, and was transferred to John Radcliffe Hospital, where a scan showed he had suffered a "brain insult".

The prognosis was poor and a decision was made to withdraw treatment, the inquest heard.

The cause of death was given as severe hypoxic ischemic encephalopathy - severe brain damage - and the inquest was adjourned to a date to be fixed.