An Inquest conducted by the Hertfordshire Coroner Service has concluded that aspects of the events leading up to the sad death in hospital of Eddie Coffey, a one-day-old baby boy were so unsatisfactory that they amounted to neglect.
The hearing at Hatfield learned that Eddie Coffey had died in the neonatal intensive care unit at Luton & Dunstable Hospital on 14 January 2019, having been transferred from the Lister Hospital in Stevenage due to major complications following his birth there the previous night.
Eddie’s 30-year-old mother, Hannah Coffey from Hoddesdon, already had a two-year-old child and was seven weeks pregnant with Eddie when, on 29 May 2018, she was assessed by the Lister Hospital as low-risk as regards antenatal care.
In August, Hannah’s history was reviewed during her visit to the hospital’s Consultant Clinic. She was already taking aspirin in view of raised blood pressure during her earlier pregnancy and she was to have third-stage active management with regular blood pressure checks from 24 weeks.
Delivery
On 13 January 2019, Hannah experienced contractions and was admitted to the midwifery-led unit at the Lister. Initial monitoring at 1815 showed that the fetal heart rate was within the normal range and it remained so for over four hours as contractions became more frequent.
At 2240, a large deceleration in heart-rate was noted and the Lister’s Consultant-led unit (CLU) was informed of this. Minutes later, Hannah was transferred to the CLU and a cardiotocograph (CTG) was commenced to monitor fetal heart rate and contractions.
Over the next 10 minutes fetal heart rate was recorded as within normal range, and birth was imminent, so a request for the Registrar to attend was cancelled. Eddie was delivered just before 2330, but his condition was concerning.
Resuscitation
The emergency buzzer was used to call for resuscitation and the neonatal team took over, with the Locum Registrar on call for Paediatrics attending.
Resuscitation was provided using an IPPV ventilator, with cardiac compression, until ETT intubation was ready at 2350. Eddie’s heart rate then fell further, prompting re-intubation with a narrower tube, and his heart rate improved.
At around midnight, the Neonatal Consultant arrived and tests of venous gas indicated metabolic acidosis, a serious electrolyte disorder. Eddie was transferred to the neonatal intensive care unit (NICU), where fluids and medication were administered while ventilation continued.
Suspecting hypoxic ischemic encephalopathy (HIE), a brain damage, the consultant arranged transfer to the NICU at Luton & Dunstable Hospital for possible therapeutic hypothermia treatment. Baby Eddie was transferred there in the early hours but sadly died later that day.
Cause of death
A post-mortem at Great Ormond Street Hospital found that the cause of Eddie’s death was perinatal asphyxia.
A Serious Incident Investigation by East and North Hertfordshire NHS Trust followed. The investigation report concluded that at a crucial time in the proceedings the CTG appeared to have recorded the mother’s heart rate, not the baby’s, thus preventing recognition of fetal hypoxia. This was likewise the opinion of independent expert evidence heard by the Coroner such that earlier identification of Eddie’s condition would have improved his outcome. Such a failing, the Coroner found, amounted to neglect.
“Correct, effective use and interpretation of a baby and mother’s heart rate is helped by a CTG machine but it still needs to be interpreted responsibly and then appropriately acted upon. Here the Coroner determined on all of the evidence that it was neglect to fail to provide such basic care to Eddie and that this may have avoided such a tragic outcome,” said specialist medical solicitor Tim Deeming of Tees Law, acting for parents Hannah and Thom Coffey. “The inquest has been very challenging for the family and whilst we understand that the Lister have been looking to improve, we want to ensure that this does not arise for any other family, especially given the findings from the national Each Baby Counts review and the concerns raised around such preventable outcomes.”
Hannah’s concern for others
“Saying goodbye to our beautiful boy only hours after he had been born has left us all with a hole in our hearts from which we will never recover,” Hannah Coffey reflects.
“Not for a moment did I imagine that we could arrive at hospital with a healthy baby and leave without him in our arms. Like many expectant parents we put our trust in the care we would receive.
Knowing that a lack of competence in the use of vital medical equipment could affect other families in a similar way is driving us to raise awareness of the need to ensure proper training and use of equipment to help save the lives of other babies.”