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Baby ward shortages 'scandalous' Baby ward shortages 'scandalous'
(about 4 hours later)
A coroner has branded midwife shortages at a hospital where a newborn baby girl died 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" and overstretched staff led to the death of Ebony McCall in May this year. An inquest heard Ebony McCall's mother, Amanda arrived at Milton Keynes General Hospital in pain and wanted a caesarean section, but was told it was too risky.
An inquest heard her mother, Amanda, who arrived at Milton Keynes General Hospital in pain, requested a Caesarian section but was told it was too risky.
Ebony was later born with only a faint heartbeat and she died soon after.Ebony was later born with only a faint heartbeat and she died soon after.
In a narrative verdict, deputy coroner for Milton Keynes Thomas Osborne said "systems failures" and overstretched staff contributed to her death in May.
Mr Osborne said it was "surprising" Miss McCall, from Milton Keynes, was not seen by her consultant until the day before she was admitted to hospital.
He said: "The situation on the labour ward became what has been described to me as 'chaotic' with far too many mums and not enough midwives."
Miss McCall's consultant Anthony Stock had earlier told the inquest: "The care in this case should have been consultant-led.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."
He said Miss McCall, who has only one kidney, was considered "low risk" in cardiac terms but when she came into hospital with stomach pain, would have been "high risk".
Amanda's father Terry McCall: "It has had a huge emotional effect on her"Amanda's father Terry McCall: "It has had a huge emotional effect on her"
"The care did not come up to a standard that I would have expected normally for a patient booked in my name."
He said Miss McCall, who was 17 at the time and has only one kidney, 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 and went into labour that night but her baby's heartbeat became erratic.Miss McCall, now 18, was admitted to hospital on 8 May and went into labour that night but her baby's heartbeat became erratic.
Medical staff said a Caesarean would be too risky, despite her own midwife supporting the request. Medical staff said a Caesarean would be too risky and she was advised to have an induced birth to ease her symptoms.
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. However Miss McCall refused because of the pain she was in and an emergency Caesarean was carried out, the inquest 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. Ebony, born at 0321 GMT on 9 May, had suffered brain damage due to a lack of oxygen and died 14 minutes later.
The three-day inquest was told that staff and bed shortages at the hospital had brought criticism. Amanda's mother, Breda McCall, told the inquest she sounded the panic alarm when she saw a monitor of the baby's heartbeat spike.
ANALYSIS By Nick Triggle BBC Health Reporter Despite the controversy over maternity standards at Milton Keynes Hospital, the NHS still provides some of the safest care in the world.ANALYSIS By Nick Triggle BBC Health Reporter Despite the controversy over maternity standards at Milton Keynes Hospital, the NHS still provides some of the safest care in the world.
There are just 3.2 deaths for every 1,000 lives births, but the overwhelming majority of these are linked to premature birth or physical defects.There are just 3.2 deaths for every 1,000 lives births, but the overwhelming majority of these are linked to premature birth or physical defects.
The rate is similar to the top-performing European countries, such as Germany and France, and better than many other rich nations, including the US and Italy.The rate is similar to the top-performing European countries, such as Germany and France, and better than many other rich nations, including the US and Italy.
But that is not to say the health service does not have its own problems. Other hospitals, including London's Northwick Park a few years ago, have faced similar criticisms to Milton Keynes.But that is not to say the health service does not have its own problems. Other hospitals, including London's Northwick Park a few years ago, have faced similar criticisms to Milton Keynes.
And while these are obviously some of the worst examples in the health service, there is still one underlying problem which can be found on almost every maternity ward in the country - staff shortages.And while these are obviously some of the worst examples in the health service, there is still one underlying problem which can be found on almost every maternity ward in the country - staff shortages.
Ask most midwives and they will say they are facing too many demands on their time, forcing them to juggle women in labour.Ask most midwives and they will say they are facing too many demands on their time, forcing them to juggle women in labour.
It was only then that her daughter was taken for an emergency Caesarean.
She said she was later told by one of the staff: "If only you had pushed that button five minutes earlier you would have saved your granddaughter."
She said: "I remember these words because I think of them every morning and every night."
Mrs McCall said her daughter's grief was compounded by the fact she was kept on a labour ward for eight days after Ebony's death.
The three-day inquest was told that staff and bed shortages at the hospital had earlier 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.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.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.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. Speaking after the inquest at Milton Keynes Civic Centre, 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 though 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.""She was born at full term and she was a healthy 7lbs 4oz and, even though 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 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."
Responding to the coroner's narrative verdict, 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.
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"
Criticising midwife shortages at the hospital, Mr Osborne said: "The situation where mothers are left unattended during labour and other mothers are unable to get an epidural is nothing short of scandalous.
"If this situation is allowed to continue the lives of babies and mothers who intend to have their babies at Milton Keynes Hospital will continue to be at risk."
Responding to the verdict, 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."
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. The Care Quality Commission 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."