Baby died after being starved of oxygen while ‘midwives joked about eating Haribo’

WARNING: Distressing content

A baby died after being starved of oxygen during birth while midwives joked about how many lollies they had eaten and how much money they earned, an inquest heard.

Theo Bradley had to be resuscitated after there were delays in his care at King’s Mill Hospital in Sutton-in-Ashfield, Nottinghamshire, in the UK, in September last year.

Mother Amelia Bradley, 26, said she called for help in agony several times but heard maternity staff chatting — including one saying: “I can’t believe how many Haribos I’ve had tonight.”

An inquest heard numerous midwives were sitting around the desk when Amelia should have been assessed within 15 minutes of arriving at hospital.

When it was recognised she had not been seen, one midwife admitted making a comment about a colleague earning more money than her due to working a bank shift.

It was nearly 40 minutes before Amelia and Theo were finally assessed, despite being the only patient in triage and Amelia’s concerns she was bleeding.

Theo was found to have a slow heartrate and a decision was made to deliver by category one caesarean, where there is an immediate threat to the life of mother or baby.

After Theo was born, resuscitation equipment on the unit was found to be missing and he was transferred to a specialist neonatal unit for treatment.

However, his condition continued to deteriorate and he died the following day in his parents’ arms surrounded by his family.

A post-mortem examination found he died from a serious brain injury caused by a lack of oxygen.

An inquest at Nottingham Coroner’s Court reached a narrative conclusion this week, with Nottinghamshire assistant coroner Elizabeth Didcock finding neglect contributed to Theo’s death.

She found that, on balance, if Theo had been delivered earlier he would have survived.

Grieving parents Amelia and her partner Luke Sherwood, 26, of Kirkby-in-Ashfield, Nottinghamshire, are now calling for lessons to be learned from the tragedy.

Amelia, who has applied to start a midwifery degree starting in September, said: “Following Theo’s death, Luke and I discussed how we wouldn’t ever want another family to have to go through what we’re going through.

“I want to honour Theo’s name and to use this awful experience to be an advocate for women and help deliver the best care and support that women should expect to receive.

“To lose Theo so soon after he came into the world is something we’ll never get over.

“We’d been looking forward to becoming a family and to have that ripped away from us in such a cruel way was nothing short of traumatic.

“To this day, I still wake up and hope it’s all been a nightmare and then it hits me and I’m completely floored by the grief.

“Knowing that our baby boy will never even celebrate his first birthday is so difficult to come to terms with.

“Hearing everything again at the inquest has been unbearable, but we’re grateful to have some answers now.

“We would do anything to bring Theo back, but we know that’s not possible.

“All we can hope for now is that no other families have to go through the heartbreak we have. I wouldn’t wish it on anyone.”

Amelia and Luke had attended King’s Mill Hospital about 9.30pm on September 13 last year after her contractions started.

They waited for more than an hour to be seen before Amelia was given pain relief and underwent a sweep and was allowed to go home about 11.30pm.

Just after midnight, Amelia started passing blood and experiencing unbearable pain and they returned to hospital.

Amelia was finally assessed at 1.42am before Theo was delivered at 2.02am.

A Healthcare Safety Investigation Branch report found there was no allocated lead in the maternity triage department, so nobody had responsibility for assigning roles and managing workload.

Both present triage midwives did not take responsibility on who would see Amelia upon her return to hospital, causing unnecessary delays in the rapid assessment.

The 29-minute delay in Theo receiving resuscitation medicines and blood products may also have impacted Theo’s outcome, the report added.

An expert obstetrician who gave evidence at the inquest stated Amelia’s presenting symptoms should have prompted an immediate assessment.

The obstetrician advised the coroner if Amelia had been assessed promptly, it was more likely than not Theo would have survived.

After the hearing, the family’s specialist medical negligence lawyer Laura Robinson, from firm Irwin Mitchell, said: “It’s less than a year since Theo died, and losing him so suddenly and in such traumatic circumstances continues to have a profound effect on Amelia and Luke.

“The pain and grief they feel has been made worse by the questions they had around the events that unfolded in the lead-up to their baby boy’s death.

“While nothing will ever make up for what Amelia and Luke are going through, we’re pleased to have at least been able to provide them with some of the answers they deserve.

“Sadly, however, the inquest has identified issues in the care prior to Theo’s death, especially around communication, training among maternity staff, and staff culture.

“Every second counts when delivering a baby in distress. It’s now vital that lessons are learned to help improve maternity safety and prevent other mums and dads from suffering the way Amelia and Luke have.

“We’ll continue to support them at this difficult time.”

Sherwood Forest Hospitals chief nurse Phil Bolton said: “I would like to take this opportunity to reiterate our unreserved apology to the family of baby Theo at what we know has been and continues to be an incredibly difficult time for them.

“Only the individuals involved that night truly know why Theo and his family did not receive the care they needed and deserved, and I am clear that we have failed to live up to the high standards of care that our communities are right to expect from their local hospitals.

“We have gone through a thorough HR process following Theo’s death to take decisive action and appropriate actions have been taken.

“We will take the coroner’s findings on board and will continue working with Theo’s family to do all we can to prevent this from happening again.”