In January 2021, Nelsons assisted Hayley Coates at a five day inquest concerning the death of her baby son, Kaylan, who died at just seven days old. The Coroner concluded that Kaylan’s death could and should have been avoided and that it was contributed to by neglect and serious, multiple failings in his care.
Kaylan was born on 23rd March 2018 at the Queen’s Medical Centre (QMC), Nottingham and was expected to be born healthy.
Hayley went into the QMC on 20th March 2018 but progressed slowly in labour. The inquest heard how Hayley wanted a C-section and the Coroner found that had this been explored, it would have been reasonable for a C-section to go ahead as a planned procedure that night and if that had happened it would have likely resulted in Kaylan’s safe delivery, avoiding the traumatic brain injury he later suffered, and which contributed to his death.
The Coroner recorded that this failure to properly and adequately explore Hayley’s wishes through a caesarean section delivery was nothing short of shocking, and that this failure had a direct link to Kaylan’s death.
Early on during Hayley’s labour, the CTG monitoring Kaylan’s heartrate showed signs of distress. However, this wasn’t interpreted correctly by medical professionals and following a very traumatic forceps delivery, Kaylan was taken straight to the neonatal intensive care unit, where it was discovered he had a fractured skull and a bleed on the brain. The Coroner found in her conclusion that the CTG is a basic tool used on a daily basis and the whole team failed to look at Hayley’s labour as a whole. The Coroner found that this resulted in a serious failure to provide a distressed baby with the care he required.
In the early hours of 23rd March 2018, Hayley was taken to theatre for a trial by forceps. The inquest heard how Kaylan’s position was assessed incorrectly. The pathologist also told the inquest that during the delivery, Kaylan’s skull was fractured by the use of forceps, leading to a bleed on the brain, causing further hypoxia.
Immediately after his birth, Kaylan was taken to the neonatal unit but sadly, after one week, he contracted a rare hospital acquired infection. At the inquest the Pathologist said that this is what took Kaylan from being a very poorly baby to the end of his life.
Following the five-day hearing, Assistant Coroner, Laurinda Bower, recorded a narrative conclusion, stating that Kaylan died as a result of an overwhelming infection against a background of hypoxia and birth trauma, which occurred due to multiple failings in his care.
The inquest comes one month after maternity services at NUH were found to be ‘inadequate’ by the Care Quality Commission (CQC), which is responsible for inspecting healthcare settings. The unannounced inspection found that the service:
“did not have enough maternity staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm, and to provide the right care and treatment”.
An inquest can be very daunting for families who are already suffering from losing a loved one. Most people have never been to an inquest before and are not sure what to expect. An inquest is a public fact-finding enquiry which considers four key questions;
- Who the deceased was;
- When and where they died;
- The medical cause of their death; and
- How they came by their death.
Inquests are vital in providing families with these answers and are often very helpful as they allow the family to ask any questions and understand how their loved one passed away.
How we supported Hayley Coates and her family
It was a privilege to work closely with Hayley and her family throughout the inquest process. A finding of neglect from the Coroner is significant because it gives the family the recognition that something serious did go wrong. Although the inquest won’t bring Kaylan back, it is hoped that his tragic death will help prevent this happening in the future.
If you have experienced poor medical treatment, our specialist team would be happy to discuss your case with you. Please contact Emily Rose or another member of the team, which has been ranked in tier one by the independently researched publication, The Legal 500, on 0800 024 1976 or via our online form for more information.