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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 girl died as "nothing short of scandalous". | |
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 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 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's consultant Anthony Stock had earlier told the inquest: "The care in this case should have been consultant-led. | |
"The care did not come up to a standard that I would have expected normally for a patient booked in my name." | |
Amanda's father Terry McCall: "It has had a huge emotional effect on her" | |
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". | |
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. | |
Medical staff said an emergency Caesarean would be too risky, despite her own midwife supporting the request. | |
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 grandfather | Had the problems been picked up it's likely she would have been with us now, celebrating her first Christmas Terry McCall, Ebony's grandfather |
The three-day inquest was told that staff and bed shortages at the hospital had brought criticism. | |
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." |
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." |