Nottingham Maternity Services Review – Bereaved Mother Calls On Parents To Share Their Experiences

On Tuesday 31 January, an interview was aired on BBC East Midlands Today concerning our client, Hayley Coates, who spoke about the loss of her week-old baby boy (Kaylan Coates) who died after a series of failings at the Queen’s Medical Centre (QMC).

Hayley is urging other parents to share their experiences with a review of the maternity service.

Review into the maternity services at Nottingham University Hospitals NHS Trust

Hayley Coates has given her consent to discussing her case openly as she is also one of the many people who have been contacted by Donna Ockenden, the senior midwife charged with conducting a detailed review of the provision of maternity services in Nottingham.

Donna Ockenden has written to a large number of families asking them to report any concerns about maternity care they may have to her. The need for the review and the concerns raised by families are extremely worrying. The enquiry is interested in speaking to those families affected by:

We have discussed the maternity review in previous articles (here and here).

Negligence claim brought by Hayley Coates against Nottingham University Hospitals NHS Trust

Hayley is represented by Carolle White from our Medical Negligence team, and they were both interviewed by the BBC regarding the events surrounding the loss of Hayley’s son, Kaylan, who was born at the Queen’s Medical Centre in Nottingham on 23 March 2018. Very sadly, after a number of failures regarding the delivery of him and his care in the neonatal unit, Kaylan died on 30 March 2018.

An inquest was opened in Nottingham and the findings of the Coroner, Ms Bower, were damming. She found multiple failures in the care the hospital Trust provided to Kaylan during the delivery and after that contributed to his death.

Kaylan was found to have died from a hospital-acquired infection together with a traumatic brain injury that occurred when the forceps used during delivery, fractured his skull resulting in a bleed on the brain. The hospital staff were found to have failed to escalate Hayley’s requests for a caesarean section. The Coroner found that had Hayley’s wishes been carried out Kaylan would have been born healthy.

Further, the CTG machine used to monitor the health of the baby was interpreted incorrectly. These readings are essential to ensure the baby is coping with the delivery. In Kaylan’s case, his heart rate was slow indicating that he was in distress something that was not picked up by the Trust staff. The Coroner also found that had the CTG readings been interpreted correctly, Kaylan would have been safely delivered by caesarean section.

Subsequently, a decision was made to proceed with delivery involving trial by forceps. By this time, the slow heart rate had been identified as an issue. However, a decision was made to proceed with vaginal delivery in spite of the fact that his slow heart rate would have meant that Kaylan was already struggling and would not have been strong enough to cope with being delivered vaginally. The hospital staff failed to accurately assess Kaylan’s position resulting in the forceps being applied incorrectly resulting in the skull fracture.

The doctor who carried out the delivery was also found to have made too many attempts to deliver using forceps and the delivery should have been converted to a caesarean section sooner. The fracture of Kaylan’s skull caused a bleed on his brain and, when he was eventually delivered, he was in a very poor state.

Following delivery, Kaylan was transferred to the Special Care Baby Unit but unfortunately, he contracted an infection, which due to the injuries sustained during the birth process, he could not fight, sadly succumbing to the infection at nearly one week old.

The Inquest found the non-airborne infection had been transmitted to Kaylan from another patient or equipment by cross-infection, something that would have been avoided had appropriate sanitising procedures been in place.

The Coroner found that Kaylan would have survived had it not been for these failures and further that his death was contributed to by neglect.

Hayley was very concerned that during the course of the delivery and giving birth to Kaylan she did not feel listened to. She had repeatedly requested a caesarean section, but her requests went unheard, and no action was taken. She was adamant that had she been listened to, her baby would now be alive.

Requests for experiences of Nottingham maternity services

Donna Ockenden has now assessed a large number of the reports she has received from families. She has confirmed that a common theme appears to be that the families involved did not feel they were listened to. This is something that will very much resonate with Hayley Coates.

Ms Ockenden is keen for other families to come forward by getting in touch via the following email address: [email protected]