A baby died as a result of neglect because hospital staff failed to follow safe breastfeeding guidelines, a coroner has ruled.
Olly Vickers died of a brain injury in February last year just weeks after two midwives at Royal Bolton Hospital let his mother Emma Clark feed him while she was having gas and air – in breach of guidelines.
Despite being well when he was born, Olly was found “pale and floppy” hours later due to his airways being obstructed. He developed a brain injury and died five months later.
Coroner Peter Sigee ruled his death was a result of “neglect” and due to a “gross failure to provide basic medical care”.
Bolton Foundation Trust has admitted negligence following a civil claim by Olly’s parents, Ms Clark and Michael Vickers.
An inquest into his death heard a student midwife placed a pillow under his mother’s arm while she was feeding him, “contrary to accepted practice”.
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Another midwife then gave Ms Clark gas and air while she was feeding Olly as she was stitched up for a tear obtained during labour – which again went against guidance.
No risk assessment was carried out and the coroner said Olly’s breastfeeding should have been stopped before the midwives began to suture Ms Clark.
Ms Clark said she became concerned about Olly’s breathing and asked staff if her son was okay, but she said neither midwife came to look at him, with one simply saying he would move himself if he was uncomfortable.
Olly’s feeding slowed further and when Ms Clark expressed concern again, the midwife repairing her tear said he was asleep and this was normal.
Olly Vickers died aged 20 weeks following failings by Bolton NHS Foundation Trust— (JMW)
Ms Clark told The Independent: “Words cannot describe the pain of losing him [Olly], it’s there every minute of every day. For the hospital to say this was avoidable if all the guidelines had been followed compounds everything. We question whether if we’d gone to a different hospital on a different day Olly would still be here.
“We want to raise awareness of the need to listen to parents, to follow the guidelines, which are there for a reason, and to ensure staff are trained in the importance of these issues. Olly was our world and losing him is something we will never fully recover from. Lessons being learned from his death is the only hope we can cling on to.”
According to a report by the Health and Safety Investigation Bureau following an inquiry into Olly’s death, hospital staff felt “pressure” to ensure he fed within the first hour as well as needing to repair his mother’s tear.
Olly is the second baby to have died following a breastfeeding incident while in the trust’s care. In 2018, Louie Bradley reportedly choked to death after his mother had been taught a breastfeeding technique that went against national guidelines. She had been left alone to feed him despite being “dog tired” after labour.
Olly Vickers, suffered brain injury following “neglect"— (JMW)
Last year, The Independent reported on the death of Kingsley Olasupo, a 10-day-old baby boy, who died after the trust failed to screen and treat him for sepsis. Bolton NHS Foundation Trust admitted clinical negligence, while a coroner ruled his death could have been avoided if he had been given antibiotics earlier. And in 2021, we revealed another tragic story of baby Alfie Rizzari who was stillborn after “systemic errors” at the same the hospital.
Law firm JMW, which is representing the Vickers family, told The Independent it was dealing with five cases where babies have suffered a brain injury or stillbirth at the hospital.
Jodie Miller, a partner at the firm, said: “This is a harrowing case and has taken an unimaginable toll on Emma and Michael.
“I am relieved that the admissions mean that they do not have to endure a lengthy legal battle and hope that the hospital providing evidence at the inquest of the safety measures that have been put in place will enable Emma and Michael to obtain further closure.
“Olly’s death is one of a number of maternity cases at Bolton that my team is dealing with and we are growing increasingly concerned about the safety of its services.”
Tyrone Roberts, chief nursing officer at Bolton NHS Foundation Trust said it had implemented new guidelines and training on supporting mums during first feeds since Olly’s death.
He said: “We fully accept that the care we gave Olly and his family was not acceptable. Whilst nothing we say can take Olly’s family’s pain away, by continuing to do everything we have outlined, our expectation is that no family will have to experience this in future. We are incredibly sorry that these mistakes were made.”
