- Ethan Benjamin Mark Phoenix Blackwell died 32 hours after being born in May 2021, due to “catastrophic” brain damage caused by oxygen deprivation during labour
- An Inquest into his death found that there were multiple missed opportunities to deliver him safely at Royal Derby Hospital
- The Trust that runs the Hospital admitted he should have been delivered by Caesarean section seven hours earlier
- Coroner confirms that with earlier delivery Ethan would not have died
- Nelsons has been supporting parents Jodie and Ben Blackwell with the inquest after a three-year wait for answers
An Inquest into the death of a baby boy concluded on 17 April 2024 that there were numerous “missed opportunities” to deliver him safe and well.
Ethan Blackwell was born at 12.30pm on May 21, 2021 and died on May 22, 2021. He had suffered “catastrophic” brain damage due to oxygen deprivation during labour.
He was kept alive in the paediatric intensive care unit until 9pm the following day, allowing his family 32 hours to spend with him and take highly cherished photos.
The inquest detailed that if Ethan had been born seven hours earlier (5.30am), at the latest, he would not have died and been a healthy baby.
Delivering her conclusion, Coroner Sabyta Kaushal described how doctors decided to carry out a category 1 caesarean-section (C-section) to deliver Ethan after he was deemed to “be at risk” around 3.28am on May 21. However, this was cancelled when his heart rate recovered. The Coroner expressed this decision was not explained effectively to Jodie and Ben, or recorded, and there was “no evidence of informed consent”.
The Coroner said there was also “no discussion of a category 2 C-section“, which would have likely taken placed within 75 minutes of a decision, adding she “found this was a missed opportunity to deliver Ethan”.
Around 5.30am, however, Ethan’s heart rate dipped again and Jodie requested to have a C-section but this was declined. The Coroner described this as another missed opportunity to deliver. The Coroner described other missed signs of infection with Jodie, and while Ethan’s heart rate was being monitored, there was a missed opportunity to also check the heart rate via ultrasound. This led to unreliable information for both mother and baby.
The Coroner also felt “concerns were not escalated” and Jodie’s views “were not taken into account”.
She added: “Had there been a full clinical review and the parents’ wishes taken into account, Ethan would have been born around 5.30am and he would have been born well.”
Hours later, Ethan was delivered with the umbilical cord wrapped around his neck in an “extremely poor condition” and was “unresponsive”. He was placed in the care of the neonatal team however he died the following day. The Coroner said Ethan died as a result of an infection within the placenta brought about through the course of a long delivery from which Ethan would not recover.
Dr Sophie Stenton, who carried out the post-mortem on the baby, told the hearing that the leading cause of death was a “very severe hypoxic brain injury“. This caused Ethan to be born with almost all of his organs having already failed and major brain damage.
The inquest heard the University Hospitals of Derby and Burton NHS Foundation Trust agree with a report’s recommendations that said there were a number of “missed opportunities” in the lead-up to his death.
The inquest took place over three days from Tuesday 2 April to Friday 5 April and was then adjourned for the conclusion on Wednesday 17 April at Derby Coroner’s Court.
A statement from Jodie and Ben Blackwell, said:
“This inquest has come after an agonising 3-year wait and just six weeks before the anniversary of our son Ethan’s death.
“We have waited a long time for answers. But we are satisfied this inquest has highlighted the areas where Ethan was failed, and where we, as parents were ignored.
“Ethan was our first-born son who we couldn’t wait to bring home. He should have never been an opportunity for a lesson to be learnt or a case to study in order to make improvements. What our baby went through should never have happened. We know he could and should have survived. Had we been given a C-section by 5.30am or as soon as possible thereafter, we would have a healthy almost three-year-old little boy at home playing with his little sister. We should have been able to bring our beautiful baby home to the place where we spent months making everything perfect for him. No apology will ever be enough. We miss him every single day and there will always be a huge hole in our family.
“While we acknowledge Royal Derby Hospital’s response and apology, we have been left with little trust in medical professionals, and it played a key part in our decision to opt for an elective C-section for our daughter’s birth – an experience that was extremely difficult for us, having to return to the same hospital where our baby boy died.
“We have both needed trauma therapy to recover and we were extremely anxious around our daughter’s pregnancy and birth, and still worry about her dying. These are the scars we have been left with that have impacted so much of the joy of having another baby. It is also crippling to know there is something missing – we see our daughter growing and learning new things, and we can’t help but think about what we have missed out on with Ethan.
“We sincerely hope that this inquest will provide lessons that will stop other babies dying in this way and begin restoring trust in our maternity services, not just here in Derby but across the country. We believe there should be a national inquiry into the country’s maternity service. Babies are losing their life too often, and it’s something that should be looked at closely. A lessons learnt report is simply not good enough.
“Until now, we have not been able to give ourselves the time to properly grieve for Ethan, or to let him rest – hopefully now we can begin to start that process and heal as a family. We are so grateful to our families, and we also wanted to especially thank Ethan’s Doctor, Dr Etewewe for doing everything possible to help our little boy.
“Finally, thank you to Matthew Olner at Nelsons for supporting us through the last few years, as well as throughout the inquest.”
Matthew Olner, Partner in our Medical Negligence team, has been assisting Jodie and Ben throughout the inquest, alongside barrister David Story who represented the family at Derby Coroner’s Court.
Matthew said:
“What Jodie and Ben have been through is something no parent should ever have to face, and I commend their bravery in being able to speak out about their experience in court. After three years of waiting, they have shown immense strength to revisit this dark time in their lives, to support this process and to hopefully bring about change.
“The inquest highlighted many concerns around Jodie’s maternity care particularly during her labour, when action was not taken despite her raising extreme concern for Ethan’s welfare.
“While these findings will not change what happened to Ethan, and provide little comfort to Jodie and Ben, it will hopefully give them some much-needed peace. Their voices have been incredibly powerful in raising awareness for these hospital failings and will hopefully assist in making changes to maternity services for other families.”