Baby died after 'ineffective intubation', inquest hears
Ineffective intubation contributed to the death of a 14-hour-old baby, an inquest has heard.
Jack Tually was born at Guernsey's Princess Elizabeth Hospital (PEH) in 2014.
His death led to a review of maternity services, midwives being struck off and political resignations.
In a verdict at Guernsey's Magistrate's Court, Judge Philip Robey said the "primary cause of death" was hypoxia caused by a rare circulatory condition.
The inquest, which initially opened in October 2017, heard from three expert witnesses who expressed the view baby Jack died of hypoxia - when a lack of oxygen reaches tissues.
It was caused by persistent pulmonary hypertension of the newborn (PPHN), the inquest heard, which occurs when a newborn baby's body does not respond properly after birth.
Delivering his narrative verdict, Judge Robey said it was not his role to express judgement or opinion.
He was unable to ascertain whether PPHN developed before or after birth, but accepted the findings of neonatal expert Dr Mark Ashton, who told the inquest a lack of effective intubation contributed to the baby's death.
"I accept Dr Ashton's opinion and find on a balance of probabilities that baby Jack's death was contributed to by the lack of effective intubation in the stated period," Judge Robey said.
Intubation is when a plastic tube is placed into a windpipe to open an airway.
Earlier this week, Dr Ashton told the inquest that with the "correct management" PPHN would have been "survivable".
In a statement, Andrew and Jesyka Tually said since their son's death they had encountered resistance "every step of the way".
"From the same institutions and individuals that were charged with the protection of our son's life or with the duty to impartially investigate his death," the statement read.
"But for the actions of one brave whistleblower at the PEH, none of the facts surrounding our son's death would have surfaced and would have remained covered up forever," the parents added.
The Tually's said an expert told the inquest the environment at Guernsey's hospital at the time was "inherently dangerous".
"We can only hope that Guernsey's politicians, senior health officials and individual clinicians take heed of Jack's case and acknowledge the limitations in care on the Island and implement better processes and procedures to ensure that complex medical situations can be managed with appropriate support and assistance from the larger/more experienced hospitals in the UK," they said.
President of Guernsey's Committee for Health and Social Care Heidi Soulsby expressed her "deepest sympathy" to Jack's parents.
"Our maternity services today are not the same as they were in 2014 as a result," she added.