Derby midwives apologise at baby boy's inquest

Two midwives involved in the care of a baby who lived for just 14 hours apologised as they gave evidence at an inquest into his death.

Zachary Taylor-Smith developed breathing problems and died at Royal Derby Hospital in November 2022.

The hospital trust said its failure to offer antibiotics to his mother during labour was "likely to have contributed".

The inquest is expected to end on Tuesday.

Zachary was born at 36 weeks after his mother Hannah Taylor-Smith was induced because of recurrent asthma attacks, the inquest heard on Monday.

He was initially in a healthy condition but soon became unwell, suffering a low temperature and poor feeding, the Local Democracy Reporting Service (LDRS) said.

Dr Shalini Ohja, a neo-natal consultant at the trust, told the hearing on Wednesday if antibiotics had been given to Zachary earlier, there would have been a "significantly" better chance of survival.

Midwives Kate James and Michelle Hankey both said they felt, in hindsight, they could have done more to prevent Zachary's death.

Ms James, an experienced midwife, said when she started her shift on the morning of 17 November 2022, her first priority was to warm Zachary up as she believed he was cold and described the room he was in at the time as "freezing".

She said that in hindsight, her actions of not escalating wider care for him after noticing his "intermittent grunting" had been an "error" and she was "truly sorry" for what happened.

"I recognised the actions that I took were incorrect," she said. "I thought I was doing the right thing.

"I believed [the grunting] was improving. It was my error not to escalate it but I was reassured it was improving.

"It should have been escalated. I should have escalated. I was falsely reassured."

Ms Hankey was reduced to tears when she gave evidence.

She explained that during Zachary's care she had become "number focused" and recognised in hindsight she should have "probed further" about his condition and that there was a "missed opportunity" to collect information.

When the inquest opened on Monday, an "admissions" statement from the University Hospitals Derby and Burton NHS Foundation Trust said there were a series of failures which were "likely to have contributed" and could have "prevented" Zachary's death.

Also on Monday, Zachary's father Tim Taylor-Smith told the inquest he felt "dismissed" by the midwife, Ms Hankey, when raising the alarm to her about his son's condition just hours after his birth.

When questioned about this, she said: "That was never the intention [to dismiss Tim]. I apologise if that is how it made you feel. That's the last thing I would do.

"In hindsight if I was in the same position, I would have escalated and sorted a review straight away."

Sarah Noble, director of midwifery at the trust, apologised on its behalf and explained the measures and changes that had been implemented since Zachary's death.

This included a new system to improve the communication of information between medical staff, as concerns were raised during the hearing about the handovers of details relating to Zachary's condition in the hours before his death.

Ms Noble also gave details on changes to mandatory training, as well as new care units at both of the trust's hospitals where babies who struggle with transitioning from leaving the womb receive more intensive support.

The trust's maternity services were rated inadequate by the Care Quality Commission in November.

The Taylor-Smiths have called for Donna Ockenden, who is leading the biggest ever investigation into NHS maternity failings, to expand her review to Derby and Burton-upon-Trent.

The inquest is expected to conclude on 12 March when all witnesses have given evidence.

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