Baby Zachary was born at the Midwifery Led Unit, Walsall on 15 October 2016, having suffered intrapartum hypoxia due to lack of oxygen during labour. He was in a poor condition and not breathing. After initial failed attempts at resuscitation, he was transferred to Manor Hospital Walsall, where some 30 minutes after birth, he was successfully resuscitated. However, by this time he had fixed dilated pupils and a decision was made to end further resuscitation attempts. Zachary passed away on 16 October 2016.
The inquest touching Zachary's death was conducted by Area Coroner Mrs Joanne Lees between 3rd and 6th February 2020.
The Coroner found that there were multiple failings on the part of the Trust:
- Zachary had been born in a birthing pool, in the absence of a working water-proof sonicaid.
- His mother was never asked to vacate the pool and his heart rate was unmonitored for a period of 38 minutes prior to his delivery. In contrast, the Trust's policy and NICE guidelines require fetal heart monitoring at 5 minute intervals during the second stage of labour.
- After delivery, the resuscitation procedure was inadequate. The ratio of chest compressions to air breaths was incorrect, and not in accordance with guidelines. There was also a period of time when no chest compressions were performed.
- There was also a failure to continue with full resuscitation and manage Zachary's airways on his transfer from the ambulance to the hospital.
The Coroner was satisfied that commutatively, the above failings amounted to a gross failure. She stated "I cannot think of anything more basic than monitoring a foetal heartbeat during the labour or having the equipment to do so, or performing resuscitation to the correct standard, until such time as Zachary is in a hospital setting."
The Trust disputed that any of the failings were causative of Zachary's death. However, the Coroner disagreed, stating that even in the absence of knowing what caused the hypoxia, that she "the absence of a cause for the intrapartum hypoxia does not prevent me from an opinion as to the effects of the lack of monitoring and the incorrect and delayed resuscitation".
Relying upon the expert evidence of Professor Steer, Professor of Obstetrics, the Coroner accepted that causation was established. In particular, Professor Steer considered that Zachary's heart rate would probably have been abnormal for 30 minutes before his birth, and that had Zachary been born 15 minutes earlier, at a location where he could have been resuscitated, he would on a balance of probabilities have survived.
The Coroner was satisfied that a "clear opportunity" had been missed, and that on a balance of probabilities the gross failure of the Trust had "caused or contributed to Zachary's death in a way that was more than minimally trivially or negligently".
The Coroner concluded by confirming her intention to make a Report with a view to prevention of future deaths and requiring further information from the Trust. She intends to share her report with the Nursing and Midwifery Council and to the Course Provider for Newborn Life Support.