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Baby ward shortages 'scandalous' Baby ward shortages 'scandalous'
(30 minutes later)
A coroner has branded midwife shortages at a hospital where a newborn baby died on an overstretched maternity ward as "nothing short of scandalous". A coroner has branded midwife shortages at a hospital where a newborn baby girl died as "nothing short of scandalous".
Deputy coroner for Milton Keynes Thomas Osborne said "systems failures" led to the death of Ebony McCall. In a narrative verdict, deputy coroner for Milton Keynes Thomas Osborne said "systems failures" and overstretched staff led to the death of Ebony McCall.
An inquest heard the baby girl only had a faint heartbeat when she was born by Caesarean section at Milton Keynes General Hospital in May this year. An inquest heard she only had a faint heartbeat when she was born by Caesarean section at Milton Keynes General Hospital in May this year.
Her mother, Amanda McCall, had medical conditions including cardiac disease. Her mother, Amanda McCall, had medical conditions and had only one kidney.
Tony Halton, director of nursing at Milton Keynes Hospital, said: "On behalf of the Trust I would like to offer the McCall family our deepest condolences.Tony Halton, director of nursing at Milton Keynes Hospital, said: "On behalf of the Trust I would like to offer the McCall family our deepest condolences.
"We are very sorry indeed for the distress and grief caused to them by the death of their daughter Ebony.""We are very sorry indeed for the distress and grief caused to them by the death of their daughter Ebony."
He added: "Changes have already been made to the way we work to further improve the safety of our maternity services."He added: "Changes have already been made to the way we work to further improve the safety of our maternity services."
Miss McCall, who has only one kidney, was admitted to hospital on 8 May with stomach pains. Miss McCall's consultant Anthony Stock had earlier told the inquest: "The care in this case should have been consultant-led.
Bed shortages "The care did not come up to a standard that I would have expected normally for a patient booked in my name."
She went into labour that night but the baby's heartbeat became erratic, necessitating the emergency Caesarean section. Amanda's father Terry McCall: "It has had a huge emotional effect on her"
Ebony was born at 0321 GMT on 9 May and died 14 minutes later. He said Miss McCall was considered "low risk" in cardiac terms but when she came into hospital with stomach pain, would have been "high risk".
The three-day inquest was told that staff and bed shortages at the hospital had brought criticism before and now the case had been referred to the Secretary of State for further investigation. Miss McCall, now 18, was admitted to hospital on 8 May with stomach pains and went into labour that night but her baby's heartbeat became erratic.
Speaking after the inquest, Amanda's father Terry McCall said: "The family and I are very relieved that the coroner has referred it back to the Secretary of State. Medical staff said an emergency Caesarean would be too risky, despite her own midwife supporting the request.
"Hopefully it will make things safer for other women giving birth in Milton Keynes. Instead, she was advised to have an induced birth to ease her symptoms, but she refused because of the pain she was in and an emergency Caesarean was carried out, the hearing heard.
Ebony was born at 0321 GMT on 9 May and had suffered brain damage due to a lack of oxygen and died 14 minutes later, a pathologist told the inquest.
Had the problems been picked up it's likely she would have been with us now, celebrating her first Christmas Terry McCall, Ebony's grandfatherHad the problems been picked up it's likely she would have been with us now, celebrating her first Christmas Terry McCall, Ebony's grandfather
"There seems to be no reason that Ebony died. The three-day inquest was told that staff and bed shortages at the hospital had brought criticism.
"She was born at full term and she was a healthy 7lbs 4oz and, even thought she had a slight infection, had the problems been picked up it's likely she would have been with us now, celebrating her first Christmas. Last year, Mr Osborne reported the hospital to the Department of Health after the death of baby Romy Feast, who was born by Caesarean section at the hospital in 2007 but died after her cardiotocography (CTG) was misinterpreted.
A Healthcare Commission investigation was launched and Mr Osborne told the hearing the 2008 report found many recommendations had not been met.
The Ebony McCall case has now been referred to the Secretary of State for further investigation.
Speaking after the inquest, Amanda's father Terry McCall said: "There seems to be no reason that Ebony died.
"She was born at full term and she was a healthy 7lbs 4oz and, even thought she had a slight infection, had the problems been picked up it's likely she would have been with us now, celebrating her first Christmas."
He added: "I am absolutely enraged to think that there was no reason for Ebony's death."He added: "I am absolutely enraged to think that there was no reason for Ebony's death."
He said Ebony's death had had a devastating impact on the family.
"During the summer instead of going around walking our new granddaughter in her pushchair we were having to go round cemeteries with Amanda as she decided where to bury her.
"The family is not interested in Christmas now, it's just not going to be the same."
Health Minister Ann Keen said: "England is still one of the safest places in the world to have a baby.
"To meet the challenges of a rising birth rate and to increase quality of care, we have increased capacity for maternity and neonatal services with additional investment and staff."
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Milton Keynes NHS Foundation Trust's Tony Halton: "We are very sorry indeed"Milton Keynes NHS Foundation Trust's Tony Halton: "We are very sorry indeed"
He said Ebony's death had had a devastating impact on the family.
"During the summer instead of going around walking our new granddaughter in her pushchair we were having to go round cemeteries with Amanda as she decided where to bury her."
The Care Quality Commission (CQC) health regulator said the coroner's findings would be used in a follow-up to the 2008 report on the maternity unit.
This said a lack of resources, mainly in the number of midwives and bed capacity, was putting maternity services at risk.
Amanda Sherlock, deputy director of frontline operations at the CQC, said: "The death of Ebony is an absolute tragedy.
"It is clear that the unit was insufficiently prepared to cope with the pressures on that particular night and that Ebony did not get the care she needed as a result."