A devastated Nottingham mum has said she has 'completely lost trust in the system' after an inquest into her baby girl's death identified missed opportunities.
Daniela O'Sullivan's daughter, Adele, died on April 7 2021 at Nottingham City Hospital, just 26 minutes after being born at 29 plus weeks.
She was born without a heartbeat, which prompted an inquest into her death that concluded on Wednesday, February 9.
Assistant Coroner Elizabeth Didcock said there were missed opportunities in a delayed examination, delayed recognition of labour, and the delayed diagnosis of the cause of vaginal bleeding.
She said that Nottingham University Hospital (NUH) staff were "reactive rather than proactive", but that, on a balance of probabilities, the management of Mrs O'Sullivan's care was not a determining factor in Adele's death.
In a statement released after the verdict, Mrs O'Sullivan said her whole family were "truly devastated" by the death of Adele.
She also said she backed calls for a public inquiry into the hospital trust's maternity services, which are currently being reviewed by the Nottingham and Nottinghamshire CCG and NHS England.
"We have completely lost our trust in the system," Mrs O'Sullivan said.
"We are distraught that I was put to the back of the queue and not reviewed by doctors for hours until it was too late.
"Adele’s post-mortem showed no genetic or physical abnormality. Despite her early arrival, she would have been a happy and healthy baby and it is extremely painful to think how she could be here with us today.
"We are yet another Nottingham family affected by baby death, therefore we are adding our voice to the calls for a full independent Public Inquiry into maternity services at Nottingham University Hospitals Trust.”
It is not the only tragedy suffered by Mrs O'Sullivan, who lost her infant son John in 2016 after he developed a condition and died a few days after birth.
The family's solicitor, Sadie Simpson, of Switalskis Solicitors, added: “The hospital concluded in their own serious incident investigation report, that 'If different actions had been taken at each stage, the course of subsequent events could have been changed'.
"The coroner found there were clear issues in Daniela’s care. Opportunities were missed to ensure that a plan of management was made for Daniela which would have meant she was properly monitored and examined during her labour.
"As a result of this inquest, the serious investigation (SI) process at NUHT has now changed which ought to effectuate more accurate and robust evidence gathering.”
Director of Midwifery at NUH, Sharon Wallis, said: “We would like to offer our sincerest condolences to Mrs and Mr O’Sullivan for the loss of their daughter, Adele.
"This was a rare, complex and truly tragic case, and we apologise from the bottom of our hearts for the delay in our medical team reviewing Mrs O’Sullivan.
"We realise this may not have affected this heart-breaking outcome, but our teams are committed to learning from this case."
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