An inquest has heard that a newborn baby would likely have survived if medics had not failed to check on him while he was in distress. Sonny Thomas Taylor died aged just three days after suffering a catastrophic brain injury.
Observations missed while mother slept
After mother Eve Taylor, 29, gave birth to Sonny via emergency caesarean section, staff at a hospital in Wales should have taken observations on the baby every four hours but failed because the mother was asleep, the hearing was told. Sonny was left distressed for a significant amount of time and died after medics failed to intervene with potentially life-saving observations.
The inquest also heard there was a 15-minute delay when the pregnant mother was taken from a maternity ward at Ysbyty Gwynedd, Bangor to a labour ward instead of straight to an obstetrics theatre.
Emergency delivery and death
Eve was rushed into theatre for the emergency C-section where Sonny was born with a low heart rate and in significant distress. The youngster was transferred to Ysbyty Glan Clwyd's Special Care Baby Unit but died with a catastrophic brain injury and sepsis, aged just three days on October 3, 2022.
An investigation by Betsi Cadwaladr University Health Board found several shortcomings. Consultant Dr Zainab Ilyas said that had observations been taken at 10pm and Mrs Taylor gone straight to theatre, it is possible there might have been a different outcome.
Midwife admits error
Midwife Hannah Cutts admitted she ought to have woken up Mrs Taylor. She told the inquest: "In hindsight I was falsely reassured with everything that had been done before and I should have woken her up at 10 o'clock."
Dr Jonathan Hurst, a consultant neonatologist who was not involved in Sonny's treatment, used a report from August 2023 to suggest a cause of death of hypoxic ischaemic encephalopathy and sepsis due to an infection of the blood stream. But the coroner said she preferred to accept the evidence of the multi-disciplinary investigation rather than some of what she had heard.
Coroner's verdict
Giving a narrative verdict, the coroner said Mrs Taylor was admitted at Ysbyty Gwynedd on September 29, 2022 with a foetus at a gestation of 36 weeks and three days. She was due to have four-hourly observations but a foetal heart rate assessment was not performed as it ought to have been at 10pm that evening.
"Taken together and with a more robust handover this would have likely changed the outcome for baby Sonny," she said. She noted that in the early hours of September 30, 2022 Mrs Taylor awoke with her baby having an abnormally low heart rate of 85 beats per minute. She was taken to theatre and her baby was born at 3.02am.
The coroner found: "Sonny's death would not have arisen at this time if the appropriate care and treatment had been provided to his mother (and) his delivery would likely have occurred earlier." She said she was only made aware of the death by the family through media reports and noted there had been learnings by the health board across Ysbyty Gwynedd, Ysbyty Glan Clwyd and Wrexham Maelor Hospital.
Family response and settlement
Sonny's mum Eve spoke about the death for the first time in January. She said at the time: "When I awoke Sonny wasn't moving as much and I immediately knew something wasn't right. What followed was frantic, chaotic, and terrifying. I went to sleep at my emergency C-section not knowing if I would wake up or whether my baby would make it."
Dad Thomas said: "The day Sonny was born should have been one of the happiest of our lives, but it turned to absolute despair. I don't think we'll ever get over leaving hospital and not taking Sonny with us to start a new chapter in our family together." The family took legal action against the health board and won an undisclosed settlement. The board's chief executive, Carol Shillabeer apologised to the family in January: "We would like to offer our sincere sympathies to the family of baby Sonny who sadly died in 2022. We are deeply sorry for their loss and for the failures in care that occurred. We recognise the profound impact this has had on Sonny's family, and we apologise unreservedly for the distress caused."
