An NHS Trust unit will hold ‘listening’ events to improve care – after a 13-day-old baby died when staff failed to communicate with a doctor who was working from home.
Daisy McCoy succumbed to a ‘lack of oxygen or blood flow’ at the Yeovil Hospital in Somerset in February, 2022.
A scan showed that prior to her birth she had sustained at least one brain injury, possibly due to issues with the umbilical cord or placenta.
However, there was a delay in carrying out the C section operation because of a ‘failure to communicate’ between staff, including the consultant who was working remotely.
The NHS Trust has now responded to a coroner’s criticisms, saying it has introduced a ‘professional disagreement policy’ and begun ‘regular walkarounds’ to ensure similar issues do not arise in the future.
The Trust also held ‘listening events’ – but has not revealed the nature of them.
The inquest heard that Daisy was born via Caesarean section at Yeovil Maternity Unit in Somerset on February 9, 2022.
Daisy’s mother later visited the hospital reporting reduced and unusual fetal movement.
Staff at Yeovil Maternity Unit, pictured, in Somerset failed to escalate the situation, and confusion between medics meant Daisy’s emergency caesarean was delayed
A scan showed the baby had suffered a brain injury due to lack of oxygen or blood flow ‘which on the balance of probabilities had occurred before delivery’.
The interruption to blood flow was ‘potentially due to a problem with the umbilical cord or placenta’.
Daisy’s parents were then left alone for an hour as they waited for an explanation as to the severity of the injury.
The consultant working remotely did not ‘fully consider’ if she should come in to assist during this time because she was unaware of staffing problems on the ward.
The unit’s guidance also did not include asking a staff member to attend if there was an issue outside of their experience or skill set.
Only the registrar was aware that the abnormal scan required a call to the consultant within 30 minutes and she did not phone in either, leading to a further delay in the procedure.
None of the staff checked the criteria for a normal foetal heartbeat and therefore did not escalate the results of the test.
The consultant told the inquest if she had been aware of the outcome she would have come on to the ward at that point.
Deborah Archer, pictured, area coroner for Devon, Plymouth and Torbay, warned there is a ‘gap’ in their policy regarding consultants or midwives attending when understaffing risks patient safety
On February 9 Daisy was moved to the larger Southmead Hospital in Bristol before being transferred at some point to a children’s hospice in Barnstaple, Devon, where she died on February 22.
Deborah Archer, Area Coroner for the County of Devon, Plymouth and Torbay, recorded a narrative conclusion that the 13–day–old had died due to an interruption in blood flow to the brain which caused ‘significant damage’ and peri natal asphyxia before her delivery.
After Daisy’s inquest, Ms Archer said: ‘[There is] A lack of adequate communication between different health care professionals on the maternity unit.’
Peter Lewis, Chief Executive of Somerset NHS Foundation Trust, also stated his response to Ms Archer’s Prevention of Future Deaths report.
‘Following the sad passing of Daisy… the Trust implemented a series of improvements’, Mr Lewis said.
He said the firm had reviewed ‘Antenatal Foetal Monitoring Guidelines’ and midwives training.
And that they had now had ‘safety walkabouts’ and held ‘listening events’.
Mr Lewis said: ‘SFT Maternity senior leaders have been actively working to understand the culture across both Yeovil District Hospital and Musgrove Park Hospital sites.
‘A number of listening events were held in 2023/24 and a programme of cultural improvement efforts rolled out in response.
‘To support improvements, the Trust launched a professional disagreement policy.
‘The trust also utilises Freedom to Speak Up Guardians (FTSU) who provide regular support to staff and conduct regular walkarounds for staff to raise any concerns.
‘The Trust has also recently engaged the national Equity Diversity and Inclusion lead to undertake a culture review diagnostic.
‘The Trust has considered all matters of concern raised… to ensure that reopening plans provide assurance of embedded change made in response to learning from Daisy May’s death.
‘We remain fully committed to embedding the learning from Daisy May’s death into every aspect of our maternity services. Our actions reflect a Trust–wide commitment to safety, transparency, and continuous improvement.’