A coroner has ruled that a baby would not have died were it not for a hospital failing. The hearing was told that observations which should have been carried out every four hours were not completed because the mother was asleep.
There was also a 15-minute delay when the pregnant mother was transferred from a maternity ward at Ysbyty Gwynedd, Bangor to a labour ward rather than directly to an obstetrics theatre.
Emergency caesarean and death
Shortly afterwards, Eve Taylor, 29, was taken to theatre for her baby to be delivered by emergency caesarean section. The baby boy, Sonny Thomas Taylor, who had a low heart rate and had been in "significant distress", 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, the inquest heard today.
An investigation by Betsi Cadwaladr University Health Board uncovered several shortcomings.
Consultant Dr Zainab Ilyas stated today that had the observations been taken at 10pm and Mrs Taylor been taken directly to theatre, it is "possible" there might have been a different outcome.
Midwife admits error
Midwife Hannah Cutts acknowledged she should have woken Mrs Taylor, telling 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 had no involvement in Sonny's treatment, drew upon a report from August 2023 to propose that the cause of death was hypoxic ischaemic encephalopathy and sepsis resulting from a bloodstream infection.
However, the coroner stated she favoured the findings of the multi-disciplinary investigation over some of the evidence presented during the hearing. Delivering a narrative verdict, the coroner confirmed that Mrs Taylor was admitted to Ysbyty Gwynedd on 29 September 2022, with a foetus at a gestation of 36 weeks and three days.
Coroner's conclusion
While she was scheduled to receive four-hourly observations, the coroner determined that 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.
The coroner noted that in the early hours of September 30, 2022, Mrs Taylor awoke to discover her baby had an "abnormally" low heart rate of 85 beats per minute. She was immediately taken to theatre, where her baby was delivered at 3.02am.
The coroner acknowledged that the health board had accepted the observations were not carried out at 10pm, and that Mrs Taylor should have been transferred directly from the maternity ward to theatre.
The coroner concluded: "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."
Family impact and apology
She stated that she was only informed of the death by the family through media coverage when the inquest was conducted. It is "entirely regrettable that it is four years on. I want to acknowledge, for his parents, I may well have reopened an incredibly traumatic period for them," the coroner added.
She explained that she had a legal obligation to proceed with an inquest. She noted there had been "learnings" by the health board across Ysbyty Gwynedd, Ysbyty Glan Clwyd and Wrexham Maelor Hospital.
Sonny's mother Eve spoke publicly 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."
"Sadly, what happened to us wasn't an isolated incident and you see and read too many stories about maternity care issues. No family wants to find themselves in the position we have but the least they deserve is for their voices to be heard so care improves for others."
Father 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 pursued legal action against the health board and secured an undisclosed settlement. The board's chief executive, Carol Shillabeer, issued an apology 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."
