Baby starved of oxygen died as midwives joked, inquest hears

A baby boy died after being starved of oxygen during birth while midwives joked about eating ‘too many Haribo’s’ and how much money they earned, an inquest heard.

Theo Bradley was resuscitated following delays in his care at King’s Mill Hospital in Sutton-in-Ashfield, Nottinghamshire. 

His mother Amelia Bradley and her partner Luke Sherwood visited the hospital on September 13 last year, after she began experiencing contractions.

She was later sent home at 11.20pm after being given pain relief, however she returned midnight in unbearable pain and passing blood.

But whilst on the ward, the young mother had to wait nearly 40 minutes before being seen – despite being the only person in triage at the time.

An inquest heard numerous midwives were sat around the desk when Amelia should have been assessed within 15 minutes of arriving at hospital. 

The mother heard one of the midwives joke: ‘I can’t believe how many Haribo’s I’ve had tonight.’

When the NHS workers realised Amelia had not been assessed, a midwife admitted to making a comment about a co-worker, who was working a bank shift, earning more money. 

Nearly 40 minutes after arriving at the hospital Amelia and Theo were finally assessed.

Theo was found to have a slow heartrate and a decision was made to deliver by category one caesarean – which is carried out when there is an immediate threat to the life of mother or baby.

After the baby was born, resuscitation equipment on the unit was found to be missing and Theo was transferred to a specialist neonatal unit for treatment.

However, his condition continued to deteriorate and he died the following day in his parents’ arms surrounded by his family.

A post-mortem examination found he died after suffering a serious brain injury caused by a lack of oxygen.

An inquest at Nottingham Coroner’s Court reached a narrative conclusion this week.

Nottinghamshire assistant coroner, Elizabeth Didcock, found neglect contributed to Theo’s death.

She concluded that if Theo had been delivered earlier, on balance, he would have survived.

Grieving parents Amelia and Luke, are now calling for lessons to be learned following the heart-breaking tragedy.

Amelia, who has applied to start a midwifery degree starting in September, said: 

‘Following Theo’s death, Luke and I discussed how we wouldn’t ever want another family to have to go through what we’re going through.

‘I want to honour Theo’s name and to use this awful experience to be an advocate for women and help deliver the best care and support that women should expect to receive.

‘To lose Theo so soon after he came into the world is something we’ll never get over.

‘We’d been looking forward to becoming a family and to have that ripped away from us in such a cruel way was nothing short of traumatic.

‘To this day, I still wake up and hope it’s all been a nightmare and then it hits me and I’m completely floored by the grief.

‘Knowing that our baby boy will never even celebrate his first birthday is so difficult to come to terms with.

‘Hearing everything again at the inquest has been unbearable, but we’re grateful to have some answers now.

She added: ‘We would do anything to bring Theo back, but we know that’s not possible.

‘All we can hope for now is that no other families have to go through the heartbreak we have. I wouldn’t wish it on anyone.’

A Healthcare Safety Investigation Branch (HSIB) report found there was no allocated lead in the maternity triage department, so nobody had responsibility for assigning roles and managing the workload.

Both present triage midwives did not take responsibility on who would see Amelia upon her return to hospital, causing unnecessary delays in the rapid assessment.

Evidence given by an obstetrician from the Trust at the inquest stated that Amelia’s presenting symptoms should have prompted an immediate assessment.

The 29-minute delay in Theo receiving resuscitation medicines and blood products may also have impacted Theo’s outcome, the report added.

An obstetrician from the Trust advised the coroner if Amelia had been assessed promptly, it was more likely than not that Theo would have survived.

Following the hearing Laura Robinson, the family’s lawyer, said: ‘It’s less than a year since Theo died, and losing him so suddenly and in such traumatic circumstances continues to have a profound effect on Amelia and Luke.

‘The pain and grief they feel has been made worse by the questions they had around the events that unfolded in the lead up to their baby boy’s death.

‘While nothing will ever make up for what Amelia and Luke are going through, we’re pleased to have at least been able to provide them with some of the answers they deserve.

‘Sadly, however, the inquest has identified issues in the care prior to Theo’s death, especially around communication, training among maternity staff, and staff culture.

‘Every second counts when delivering a baby in distress. It’s now vital that lessons are learned to help improve maternity safety and prevent other mums and dads from suffering the way Amelia and Luke have.

‘We’ll continue to support them at this difficult time.’

Phil Bolton, Chief Nurse at Sherwood Forest Hospitals, said: ‘I would like to take this opportunity to reiterate our unreserved apology to the family of baby Theo at what we know has been and continues to be an incredibly difficult time for them.

‘Only the individuals involved that night truly know why Theo and his family did not receive the care they needed and deserved, and I am clear that we have failed to live up to the high standards of care that our communities are right to expect from their local hospitals.

‘We have gone through a thorough HR process following Theo’s death to take decisive action and appropriate actions have been taken.

‘We will take the Coroner’s findings on board and will continue working with Theo’s family to do all we can to prevent this from happening again.’