Mum repeatedly turned away by hospital before baby died days after birth, inquest told

A young mum whose baby died soon after she gave birth was turned away from a hospital repeatedly despite suffering labour pains, an inquest heard.

Zak-Ezra Carter died at the Royal Gwent Hospital in Newport two days after his birth at Ystrad Fawr Birth Centre in Ystrad Mynach Ystrad Mynach on July 20, 2018.

Mum Adele Thomas had gone into labour early in the morning and grew more frustrated as her pain and discomfort increased, Gwent Coroners’ Court heard today.

Summarising a statement written by the first time mum, senior coroner Caroline Saunders said Ms Thomas and her partner went to the birthing centre at around 5am, around 90 minutes after her waters broke.

She was given tests and told to go home before returning to be assessed at 9.20am and again told she wasn’t ready to be admitted, reports WalesOnline.

The court heard Ms Thomas’ partner called the centre again at 11.30am and she heard nurses tell him that if they came back nurses would examine her again and send her home.

Ms Thomas said she waited for “as long as she felt able” but returned to the birthing centre at about 12.30pm.

There she said she was given a birthing pool but was told she would be better off at home as she was only 3cm dilated, but was finding it difficult to walk.

“I started to feel scared,” she said. “This was my first pregnancy and I was in pain. I was deeply unhappy that they kept sending me home.”

At about 4.30pm she said she returned to the hospital with her partner and mother. On this occasion she was admitted after nurses found she was 7cm dilated.

“I do not remember much from this time,” she said. “I do remember asking for pain relief and being offered paracetamol. I thought I should be on gas and air by this point.”

Giving oral evidence, Theresa Ward, a former registered midwife at Ysbyty Ystrad Fawr Birthing Centre, who has since retired, said stage two of the labour began at 6.05pm.

She checked in on the room as she had been “concerned” about some observations she made of fellow midwife Lisa Gibson during an earlier birth.

“There was one or two issues with the birth that I wasn’t happy about and I had gone to the managers about it,” she said, adding she told them: “I wasn’t too happy about Lisa being there during the pushing stage.”

On arrival in the room Ms Ward said she was not able to locate the partogram, the document used to record observations during labour.

She said she also had concerns about Ms Thomas’ position on the bed so changed her position to sit more upright.

During stage two of labour Ms Ward said the foetal heart rate should be monitored every five minutes and recorded on the partogram, but this had not been done.

She said she did this every five minutes from there with a sonic aid, but did not make an attempt to look for the partogram or record her observations on a replacement document.

Shortly before the point of birth Ms Ward said she stopped being able to hear a heart rate and informed her colleague, who said she could hear it “faintly”.

Ms Ward said she sat Ms Thomas back but still couldn’t hear the baby’s heart so told her colleague to “get the baby out”, adding the child was born to the point of the chest at about 7.14pm.

The court heard Zak-Ezra was taken to a neighbouring resuscitation room and an ambulance was called.

When doctors from elsewhere in the hospital arrived to assist Ms Ward said they requested equipment including a cannula, which was needed to aid the resuscitation of the child but they had been “removed”.

A post mortem found the child had died from hypoxic ischemic brain damage with myocardial infarction caused by perinatal asphyxia.

The inquest continues.