A midwife made "catastrophic" and "inexplicable" failings that led to a newborn baby's death, then tried to blame colleagues, an inquest has heard. Isabelle Stephens was born in September 2021.
A two-day inquest heard parents Emily Bullock and Oliver Stephens had expected to bring their healthy baby girl home that day, instead she never took a first breath.
Assistant coroner Guy Davies, ruled that Isabelle's death could have been prevented and that failures were made. He said: "Isabelle died on September 19, 2021, 36 minutes after being born without taking a breath. Her death was due to a catalogue of catastrophic and inexplicable failings made by the responsible midwife who accepted that she'd made a massive error of judgement but falsely blamed or sought to blame understaffing and the demands of colleagues to try and deflect from her culpability."
He said that Louise Pouget, the responsible midwife at the birth at Royal Cornwall Hospital, at Treliske, Truro, failed to recognise the start of the different stages of labour and, consequently, there was a failure to commence intermittent monitoring of the foetal heart rate in accordance with medical guidelines. When monitoring did finally commence it was incorrectly and inaccurately measured, reports CornwallLive.
He found that Ms Pouget did not disclose any concerns during the delivery although she later said she did have concerns and as a consequence of her failure to disclose this at the time - Isabelle's condition at birth was not anticipated by colleagues who made attempts to save her.
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"That had a knock on effect to the ability of the medical team to respond to the crisis that had developed," Mr Davies continued. "There was no preparation made for an emergency scenario and that further delayed the identification of the extent of Isabelle's distress and it took crucial minutes for the full extent of Isabell's condition to be identified after delivery."
He said the neonatal emergency team was then called but there was insufficient time for the team to save Isabelle's life. "The failings deprived the emergency team of the time they required to try and save Isabelle and my finding is that given sufficient time it is likely that Isabelle's life would have been saved."
Ms Pouget, who has more than 22 years' experience in midwifery, has removed herself from the midwifery register following the incident. She said she "made a massive error of judgement" that "she will have to live with for the rest of [her] life".
She blamed the human error she made on the day on high stress levels brought on by what she called "unsafe levels of staffing" and distracting colleagues. Royal Cornwall Hospitals Trust director of midwifery Sally Britton denied there were inadequate or unsafe levels of staffing that day, insisting there were enough midwives, supporting staff and consultants working that day as per the guidelines.
Mr Davies continued: "[The midwife] gave an account which, while accepting some blame, sought to deflect some of the blame for Isabelle's death on understaffing and calls for help from what she described as inexperienced colleagues. In effect she was suggesting they were unnecessarily distracting her from Emily's labour and I do not accept the evidence of midwife Pouget because we heard evidence from hospital witnesses which clearly indicated that staffing levels were appropriate and safe and if further staff were needed there were available resources."
He said during delivery Ms Pouget allowed the maternity supporter to film the birth rather than being deployed to assist. Ms Pouget also admitted to making an error in judgement and did not at any point express any concerns to her colleagues about Emily's labour in the lead-up to delivery which he said "misled" colleagues.
A report by the Healthcare Safety Investigation Branch (HSIB) looked at what happened on the day of Isabelle's death. Mr Davies found that he was satisfied that the number of safety recommendations made by the report were now addressed and said they did not affect the outcome of Isabelle's death.
"Culpability rests with the failings that lie at the door of the responsible midwife who made those inexplicable and catastrophic blunders which I've referred to," he said. As a result he found there was a clear causal direction between the "gross failure" and Isabelle's death and made a finding of neglect. He gave a cause of death as perinatal asphyxia contributed to by neglect.
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