Yesterday (Tuesday, 26th January), a Coroner’s Court found that a baby’s death ‘could and should have been avoided’ and was ‘contributed to by neglect’ and ‘serious, multiple failings’ in his care.
Kaylan Coates was born on 23rd March 2018 at the Queen’s Medical Centre (QMC), Nottingham. He was a baby boy who was expected to be born healthy, the inquest into his death – which took place at Nottingham Coroner’s Court – heard.
However, during his delivery he suffered prolong ed bradycardia, a slow heart rate, and associated hypoxia, a condition where the brain is starved of oxygen. 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.
A week after his birth, Kaylan contracted a hospital-acquired pseudomonas infection as a result of cross-infection from another patient on the unit, which was likely transmitted by a member of staff or shared equipment. Due to his already weakened condition, the infection – along with the hypoxia – caused his death on 30th March 2018.
Following a 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.
Speaking on behalf of Hayley, who is currently on maternity leave after having her second child, Sienna, in March 2020, Emily said:
“The inquest raised many concerns about the care Hayley, then aged 24, received while on the maternity ward and the delivery of her first-born child, Kaylan.
“Hayley went to the QMC on 20th March – at this point, she was already one week overdue. She was put on a ward and given a pessary to induce labour, but it did not work. The next day, she was taken to the labour ward where she had her waters broken and it was not until 23rd March that Hayley gave birth.
“The inquest heard how Hayley wanted a C-section and in a statement to the police in 2018, her birth partner said she was asking for this mode of delivery, but no one would pay attention to her. When giving her conclusion, the coroner said that if a C-section would have been performed, it would have likely concluded with Kaylan’s safe delivery – avoiding the traumatic brain injury he later suffered, which led 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 said the CTG is a basic tool used on a daily basis to assist in assessing foetal wellbeing and that the whole team failed to look at Hayley’s labour holistically, which resulted in a serious failure to provide a distressed Kaylan with the care he required.
“Kaylan survived for a week before contracting a pseudomonas infection, which, according to the pathologist at the inquest, is what took Kaylan from being a very poorly baby to the end of his life. The coroner said Kaylan was one of three babies on the neonatal intensive care unit who tested positive for the infection, highlighting that infection-prevention methods were not followed as closely as they should have been.
“As she was overdue and in a slow labour, Hayley was a high-risk patient. However, the midwife allocated to Hayley was newly-qualified – despite it being a quiet evening on the maternity ward, according to witness statements. In her conclusion, the coroner said that on the night before Kaylan’s birth, there were long periods of time where staff on the ward were socialising and online shopping.
“It wasn’t until five hours after giving birth to Kaylan that Hayley was able to see him, and what she saw will be ingrained in her mind forever – she was broken and in shock at seeing her child laying lifeless in an incubator on a ventilator, wrapped up in a cooling blanket and surrounded by lots of wires.
“For the first few months after Kaylan’s death, Hayley didn’t leave the house. The death of her baby boy has affected her mental health and up until the conclusion was delivered by the coroner, Hayley had no idea how her first-born baby had died.
“While the inquest won’t bring Kaylan back, it is hoped that his early, tragic and avoidable death will help prevent other parents from suffering the same devastating loss as Hayley and her family. We are currently working with Hayley and her family and looking into whether or not legal action against the hospital is appropriate.”
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”.
Barrister, Ross Beaton, from 7 Bedford Row represented the family in Court during the hearing.