Parents describe 'devastating' death of Portsmouth baby at Queen Alexandra Hospital after 'blinkered' view of midwives
TWO parents have told of the ‘devastating’ death of their baby son after a coroner ruled he could have survived had midwives not been ‘blinkered’.
Little Edward Rydiard died at Queen Alexandra Hospital shortly after being born in a high-risk pregnancy wrongly assessed as being low risk, an inquest heard.
Winchester Coroner’s Court was told how mum Laura Rydiard, 34, from Milton, had repeatedly asked about having a caesarean and seeing an obstetrician but this did not happen.
This is despite midwives recording a ‘spurt’ in the baby’s growth, noticing light meconium and Mrs Rydiard twice reporting experiencing a reduction in foetal movement.
Mrs Rydiard told the inquest that by the time she went into labour she was ‘exhausted’ having been induced at 40 weeks plus 15 days.
Complications during labour at QA Hospital - which has admitted shortcomings in its care - saw an obstetrician called to deliver Edward fully as he had shoulder dystocia.
A displaced shoulder had initially prevented his full delivery until 3.34am on the day of his birth, October 17, 2019.
The inquest heard Edward was delivered and taken to neonatal intensive care for resuscitation as his cord had tragically been compressed before being born.
Mrs Rydiard had told the inquest the birth was ‘hugely traumatic’ and she has flashbacks.
‘I understand that everybody did what they could to manage Edward being delivered in those final stages,’ she said.
‘Seeing him in the NICU at the end was just the hardest thing but we’re grateful that we got to hold him at the end.’
She added: ‘I went on what was advised, I didn’t feel I was given enough information for the choice, I think is probably the right word, about what came next.
‘The only option was induction even though I had asked about caesarean section.’
She told The News his death had been ‘devastating and life-changing,’ and both she and her husband Mike had since poured their energy into raising £7,000 for Sands, the stillbirth and neonatal death charity.
They both ran the virtual Great South Run last year and Mike, 34, ran the London Marathon this year to raise awareness and funds for Sands.
In a joint statement Edward’s parents said: ‘Edward will always be part of our lives and will never be forgotten.
‘We would like to thank our family and friends who's love and support has helped us so much over the last two years.’
They said they ‘hope that the lessons learned can be taken forward by the trust to ensure families do not suffer such devastating loss in the future’.
After hearing two days of evidence, coroner Rosamund Rhodes-Kemp made a narrative conclusion and said: ‘Had mother been offered a caesarean section it is likely she would have chosen this option and Edward would have in all likelihood avoided the catastrophic... injury that resulted in his tragic death.’
She added midwives - who wept as they gave evidence - were caring but ‘blinkered in terms of the risk to the baby at this stage’.
‘It’s as though they were on a course and they were going to follow the course and hadn’t taken into account the factors leading up to the situation that Laura and Mike found themselves in,’ she said.
At the inquest, Liam Duffy, representing Portsmouth Hospitals University NHS Trust, gave the trust’s ‘apologies for the shortcomings in care which have been identified’.
Edward’s death on the morning of his birth sparked an internal investigation and one by the Healthcare Safety Investigation Branch, leading to several recommendations being made.
Maternity investigator Lorna Sugden said these include improved staff training, ensuring a ‘holistic assessment’ and implementing the NHS Saving Babies Lives Care Bundle.
Ms Sugden said the recommendations have been ‘acted upon,’ and the coroner said the trust ‘should be commended for their work since this happened’.
But Mrs Rhodes-Kemp said a divide between midwifery and obstetric-led care was ‘at the very heart of this’ case.
She said: ‘It’s a cultural problem and it’s endemic and it’s really serious because until it stops and there’s a working together we will carry on seeing Edwards in my view, we will carry on seeing little Edwards.
‘Laura Rydiard was quite specific she wanted to see an obstetrician. She didn’t.’
The coroner said there should not be a focus on either doctor or midwife-led care, but instead it should be ‘about care of mum and baby’.
QA Hospital director of maternity services and midwifery Lynn Woolley said maternity notes had since been digitised, and more training has been done.
All patients on a labour ward should now be reviewed by a consultant during ward rounds and ‘this is one of the biggest cultural changes,’ said Nirmala Vaithilingam, a consultant in obstetrics and gynaecology.
Giving evidence at the inquest, Professor Tim Draycott said the handling of Edward’s shoulder dystocia was good.
But he added medics ‘can’t prevent’ cord compression and this was a ‘tragic accident’.
In a statement after the inquest, QA’s chief nurse Liz Rix said: ‘The death of any child is tragic and life changing for all of those involved, and I would once again like to offer my condolences to Edward’s parents.
‘We are continuously working to improve the standard of care we offer women and their babies, and have already ensured the actions that came out of our investigation into how we cared for Edward and his mother are being acted on.
‘I would like to express our absolute commitment to working with, listening to and learning from families when something unexpected takes place or they feel we have not provided the level of care they expect from us.
‘As a trust we will continue working and training together across different teams and there are a number of development processes in place to support this going forward.’
A Care Quality Commission report in July said there were ‘further improvements’ needed at the hospital’s maternity services with low staffing levels among the problems. Recruitment has since taken place.
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