Neglect by Jersey midwives contributed to the death of a one-month-old baby in 2018, a coroner has concluded.
Amelia Clyde-Smith suffered “acute and irreversible brain damage” during her birth and died aged 33 days.
The inquest concluded on Friday after a five-day hearing at International House, St Helier.
Coroner Bridget Dolan KC said “cumulative failures” by the midwifery team resulted in a “gross failure of basic midwifery care”.
In 2019, the island’s Health and Community Services department apologised for Amelia’s death – an apology the medical director repeated at the inquest earlier this week.
The inquest heard that Amelia’s medical cause of death was brain damage caused by a lack of oxygen to the brain and a type of pneumonia in her lungs.
In her official findings, Ms Dolan said the development of brain damage “had been contributed to by neglect when on the labour ward”.
She said Amelia “suffered” from a lack of oxygen “around the time of her birth due to failures in the maternity care provided to her mother”.
She added: “There had been a number of shortcomings in the management of the labour and unwarranted delay in Amelia’s delivery.”
Among her findings, Ms Dolan said there was “systemic failure” on the part of Jersey Hospital to update their polices on the induction of labour, and that there had been a “lost opportunity to deliver Amelia earlier”.
Ms Dolan said this could have prevented the damaging loss of oxygen.
She said there were “failings” in “basic midwifery care” – including not properly monitoring Amelia’s heart rate before she was born.
The inquest also heard that the supervising midwife was unavailable for much of the time Amelia’s mother was in labour.
It found there was a lack of supervision of midwives.
Amelia was born on 19 August 2018 and died on 21 September 2018.
After the inquest, Amelia’s parents Ewelina and Dominic Clyde-Smith said they were “grateful for the findings” of the coroner.
Mrs Clyde-Smith said: “This has been a long process, in which we have always maintained that there was gross failure to provide medical care to Amelia.
“We feel that the inquest has investigated the matters thoroughly… although our pain after losing Amelia remains the same, the fact that the circumstances of her death were acknowledged and investigated gives us reassurance.”
‘Serious shortcomings’
Chris Bown, chief officer of Health and Community Services, said the findings highlighted “serious shortcomings” in Amelia’s care, but that the government “accepted liability for her death some time ago”.
He said: “Once more we would like to extend our deepest condolences to Amelia’s parents and to apologise unreservedly for these failings.
“We are deeply sorry for the pain and suffering that Amelia, her parents and her wider family went through.”
Mr Bown said since her death, “significant improvements” had been made to maternity care in Jersey, including the appointment of a new permanent Director of Midwifery, and additional consultants and midwives.
He said: “We are constantly striving to improve maternity services in Jersey in order to make them as safe as possible for mothers and babies, but we are not complacent, and we continue to work closely with all the families who use our services to find ways of making further improvements.
“We will now carefully review the Coroner’s findings and will ensure that if any further action or learning is required this will be properly investigated and addressed.”
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