A coroner has slammed the care given to a mother whose week-old baby died following a catalogue of hospital blunders as ‘nothing short of shocking’.
Tiny Kaylan Coates suffered serious injuries including skull fractures during a forceps delivery and died from a hospital infection days later.
Staff at Nottingham’s Queen’s Medical Centre ignored pregnant Hayley Coates’ pleas for a Caesarean section and did not spot her baby’s signs of distress, an inquest was told.
Despite being a high-risk patient, she was allocated a newly qualified midwife – and maternity ward staff failed to monitor her properly despite having time to socialise and shop online, a legal representative for Ms Coates told the inquest.
Now a coroner has ruled that the tragedy, which left the young mother ‘broken and in shock’, ‘could and should have been avoided’ and neglect contributed to her baby’s death.
Kaylan was born on March 23, 2018 at the QMC in the city. During the delivery, he suffered prolonged bradycardia, a slow heart rate, and associated hypoxia, a condition where the brain is starved of oxygen.
A pathologist told Nottingham Coroner’s Court when Kaylan was finally delivered his skull was fractured by the use of forceps, leading to a bleed on the brain, causing further hypoxia.
At the end of a five-day hearing, Nottinghamshire Assistant Coroner Laurinda Bower returned a narrative verdict saying while an infection was the primary cause of death, neglect and ‘serious, multiple failings in his care’ had contributed to this.
Tiny Kaylan Coates suffered serious injuries including skull fractures during a forceps delivery and died from a hospital infection days later. Staff at Nottingham’s Queen’s Medical Centre ignored pregnant Hayley Coates’ pleas for a Caesarean section and did not spot her baby’s signs of distress, an inquest was told
The court was told that following a normal pregnancy Miss Coates, 28, from Broxtowe, Nottingham, went into the hospital on March 20, 2018 to be induced, but this progressed slowly.
Two days later, she was noted as ‘struggling’ and the coroner found she requested a Caesarean section.
Tragically doctors did nothing, an omission Ms Bower described as ‘nothing short of shocking’.
Ms Bower said: ‘If Miss Coates’ wishes had been properly explored, as they ought to have been, she would have maintained her wish for a Caesarean section delivery, and it would have been reasonable to have performed the same as a planned procedure that night before Kaylan’s condition deteriorated.
‘These failures led to a missed opportunity to have delivered Kaylan safely and would probably have avoided his death.’
When Miss Coates, who was 24 at the time, was eventually taken into the labour suite Kaylan’s position was incorrectly identified and when forceps were used, his heart rate dropped dangerously.
After his birth he was in a ‘poor condition’ and scans showed Kaylan had suffered a fractured skull, associated bleeding and brain damage due to lack of oxygen. He was placed on a ventilator.
As the night progressed both doctors and midwives did not treat changes in the baby’s heart rate with the seriousness it demanded.
Ms Bower found Kaylan’s heart rate monitor reading was ‘miscategorised on multiple occasions’ and the alarm was not raised properly.
She said this was ‘a really serious failure to provide a distressed baby with the care that he obviously required’.
‘It is accepted that this failure has more than minimally contributed to death, and therefore it is sufficient to underpin a finding of neglect,’ Ms Bower said.
After initially responding to treatment Kaylan caught a more serious infection, which was not picked up in time to be treated properly.
Now a coroner has ruled that the tragedy, which left the young mother ‘broken and in shock’, ‘could and should have been avoided’ and neglect contributed to her baby’s death
He contracted a hospital-acquired pseudomonas infection as a result of cross-infection from another patient on the unit, which was probably transmitted by a member of staff or shared equipment.
Due to his already weakened condition, the infection took its toll and he died on March 30, 2018.
Ms Bower concluded that Kaylan died as a result of an overwhelming infection against a background of hypoxia and birth trauma, which occurred due to multiple failings in his care.
After the hearing the family’s solicitor Emily Rose spoke on behalf of Hayley, who is currently on maternity leave after the birth of her second child, Sienna, in March 2020.
She said: ‘When giving her conclusion, the coroner said that if a C-section would have been performed, it would have likely concluded with Kaylan’s safe delivery, avoiding the traumatic brain injury he later suffered, which led to his death.
‘The coroner recorded that this failure to properly and adequately explore Hayley’s wishes through a caesarean section delivery was nothing short of shocking, and that this failure had a direct link to Kaylan’s death.’
Describing the moment her client saw her baby laying life less in an incubator she said it had left her ‘broken’.
‘For the first few months after Kaylan’s death, Hayley didn’t leave the house.,’ she added.
‘The death of her baby boy has affected her mental health and up until the conclusion was delivered by the coroner, Hayley had no idea how her first-born baby had died.
‘While the inquest won’t bring Kaylan back, it is hoped that his early, tragic and avoidable death will help prevent other parents from suffering the same devastating loss as Hayley and her family.’
The finding of the inquest comes a month after maternity services at NUH were found to be ‘inadequate’ by the Care Quality Commission (CQC), which is responsible for inspecting healthcare settings.
The unannounced inspection found that the service ‘did not have enough maternity staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm, and to provide the right care and treatment’.
Nottingham University Hospital Trust’s medical director, Dr Keith Girling, said: ‘We are deeply sorry that this tragic incident happened and would like to offer our sincerest condolences to Miss Coates and her family.
‘Our teams had to make some challenging decisions and regretfully missed opportunities on the day that Kaylan was born in March 2018. Our learning from this will inform part of the improvements we are making to our maternity services.’