A baby boy lived for just 14 hours following ‘total and complete failures’ in his care, an inquest has found.
Zachary Taylor-Smith’s death could have been prevented had his mother, nurse Hannah Taylor-Smith, 33, been given antibiotics, a hospital trust admitted.
Zachary was born at Royal Derby Hospital at 36 weeks in November 2022 after Mrs Taylor-Smith was induced because of recurrent asthma attacks.
He was initially in a healthy condition but soon became unwell, suffering a low temperature and poor feeding.
Medics should have started treatment for the Group Strep B infection that Zachary contracted during his birth but failed to escalate his care.
His mother and father, blind-fitter Tim, 39, said they were not listened to when they alerted hospital staff to Zachary’s deterioration.
The inquest heard that ‘basic’ and ‘obvious’ errors were made while records were misplaced, a doctor forgot to review and handover Zachary, obvious signs of an unwell baby were missed, charts were not completed, and the pathway designed to ensure ill babies are escalated was not followed – not once but repeatedly.
The inquest heard he should have been reviewed by a neo-natal doctor at birth and urgently on at least five occasions but was finally only seen when the couple pressed the crash bell themselves but by then it was ‘too late to save him’.
Mrs Taylor-Smith told the hearing: ‘My world is full of darkness now. None of this will never make sense.’
Recording a narrative verdict at Chesterfield Coroner’s Court yesterday, coroner Susan Evans said there were multiple ‘missed opportunities’ to refer Zachary to a neo-natal team that, on the balance of probabilities, would have prevented his death.
The coroner said there were ‘total and complete failures’ relating to the provision of basic care, and ‘gross failings’ relating to the fundamental requirements of patient care.
Mrs Evans, who ruled neglect contributed to his death, confirmed she would be writing a prevention of future deaths report over Zachary’s death.
In a statement his parents said their son – their fifth child – was ‘perfect in every way’ adding: ‘There is no pain like watching your child pass away and being totally helpless to stop it.’
The couple, from Lichfield, Staffordshire, are joining a nationwide campaign calling for a national inquiry into maternity services following scandals at hospitals around the country.
They said: ‘From speaking to other bereaved families, we know that this is not just happening in one trust or in ‘dark corners’ of the NHS. It is widespread and babies are dying unnecessarily.’
Royal Derby Hospital’s maternity services were downgraded to ‘inadequate’ by the Care Quality Commission in November.
Nicola Wainwright, a partner at JMW Solicitors London office specialising in maternity failures, who is representing the family, said: ‘The evidence we heard suggests that once Hannah was in hospital for Zac’s delivery, there were negligent failings by nearly every single member of staff who saw her or Zac prior to his collapse.’
University Hospitals of Derby and Burton NHS Foundation Trust (UHDB), which runs the hospital, said changes have been implemented to improve services.
Garry Marsh, executive chief nurse at the trust, said: ‘The loss of a baby is devastating and we are sincerely and deeply sorry for the failings in Zachary’s care, which we fully accept.
‘We should have provided antibiotics and responded differently to changes in Zachary’s condition and we have been determined to put changes in place.’