A baby died after being starved of oxygen during his birth while midwives joked about how many sweets they’d eaten and how much money they earned, an inquest heard.
Mother Amelia Bradley waited 40 minutes for assessment when she was admitted to hospital in labour with her son Theo, despite her being the only patient in triage, and being in pain and bleeding.
Ms Bradley, 26, told the hearing at Nottingham coroner’s court she called for help in agony several times, as she heard maternity staff chatting, including one saying: “I can’t believe how many Haribos I’ve had tonight.”
The inquest heard several midwives were sitting around the desk when Ms Bradley should have been assessed within 15 minutes of her arrival.
One midwife admitted making a comment about a colleague earning more money than her because she was working a bank shift.
When Ms Bradley was finally assessed at King’s Mill Hospital in Sutton-in-Ashfield, Notts, Theo was found to have a slow heart rate and a decision was made to perform an emergency caesarean, the inquest heard.
After he was born, resuscitation equipment on the unit was found to be missing and he was transferred to a specialist neonatal unit for treatment.
But he died the following day. A post-mortem found he had suffered brain injury caused by lack of oxygen.
Elizabeth Didcock, the assistant coroner for Nottinghamshire, found neglect contributed to Theo’s death and that, on balance, if he had been delivered earlier, he would have survived.
Ms Bradley, who has applied to start a midwifery degree, and her partner Luke Sherwood, 26, of Kirkby-in-Ashfield, are now calling for lessons to be learned following the tragedy.
She 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.
“Hearing everything again at the inquest has been unbearable, but we’re grateful to have some answers now.”
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 workload.
The 29-minute delay in Theo receiving resuscitation medicines and blood products may also have affected his outcome, the report added.
An obstetrician from the Sherwood Forest Hospitals NHS Trust, which is responsible for the hospital, told the inquest that if Amelia had been assessed promptly, it was more likely than not that Theo would have survived.
Laura Robinson, the specialist medical negligence lawyer at Irwin Mitchell representing the family, said after the hearing: “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.”
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