Prince Charles Hospital: Baby died due to 'systemic failures'
A newborn baby died due to a number of "systemic failures" in his care at a Welsh hospital, a coroner has said.
Returning a narrative verdict, coroner David Regan found Jenson James Francis died 40 minutes after he was born.
His mother Tiffany Gillard gave birth to him at Prince Charles Hospital in Merthyr Tydfil on 21 June 2018.
The head of midwifery at Cwm Taf health board said a number of changes had since been implemented. Its maternity services are in special measures.
Ms Gillard told the inquest that when she was told what had happened, she was left "shocked and numb".
Mr Regan found Jenson died of cardiopulmonary failure due to "a failure to deliver him in good time, exposing him to the effects of developing maternal sepsis".
Pontypridd Coroner's Court heard evidence from Dr Pina Amin, the obstetric lead at the University Hospital of Wales (UHW) in Cardiff, who was asked to look at the case.
Referring to the cardiotocography (CTG) reading - a recording of the foetal heartbeat and uterine contractions - Dr Amin indicated a caesarean section delivery should have been offered to the mother about six hours before the baby was actually delivered at 05:20 BST.
The CTG was "abnormal" from 22:21 on 20 June which Dr Amin said "would tell me this baby is not happy".
She suggested CTG training in Cwm Taf health board "needs to be such that it's actually fit for purpose".
She told the hearing "ineffective communication" resulted in "a dysfunctional team without a clear leader".
Dr Amin interviewed staff on the maternity unit ahead of the inquest and said they appeared to have a reluctance to ask for help because "maybe they might be seen as not being able to cope".
Another independent expert who was asked to review the case said there were "systemic issues" which led to baby Jenson's death.
Dr Helen Claire Francis, a consultant obstetrician and gynaecologist at UHW, said "incorrect interpretation" of the CTG readings "played a big role".
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Dr Francis said when a second opinion on the CTG readings was sought, "it wasn't always correct".
She also raised concerns that there was "no thought" to escalate to senior members of the clinical team.
Although she acknowledged a midwife might not have been as skilled as senior member of the team, Dr Francis said the CTG "should have been picked up" over the course of the evening.
The inquest also heard from Cwm Taf health board's head of midwifery, Kerri Eilertsen-Feeney.
She told the inquest that training for her staff "is the same as what is offered across Wales", adding that a number of changes had been implemented prior to the publication of the critical report.
Ms Eilertsen-Feeney said work was under way to change the culture within the health board so junior staff would feel able to "jump call or query senior staff".
"But cultural changes can't happen over night," she added.