A hospital trust in Somerset has pledged to hold a series of 'listening' events and implement new safety policies after a tragic incident where a 13-day-old baby died. The death followed a critical failure in communication between hospital staff and a consultant who was working from home.
A Tragic Sequence of Failures
Daisy McCoy was born via Caesarean section at the Yeovil Maternity Unit in Somerset on 9 February 2022. Prior to her delivery, a scan revealed she had sustained at least one brain injury, likely due to problems with the umbilical cord or placenta which caused a lack of oxygen or blood flow.
However, an inquest into her death heard there was a dangerous delay in performing the emergency C-section. This was primarily due to a 'failure to communicate' among staff, including the consultant who was working remotely. The consultant was not made aware of the severity of the situation or staffing issues on the ward, and therefore did not consider coming into the hospital to assist.
Furthermore, none of the staff present properly escalated the abnormal scan results or checked the criteria for a normal foetal heartbeat. The unit's guidance also lacked clear instructions for staff to call for assistance when facing a situation beyond their experience.
Coroner's Report and Trust's Response
Area Coroner for Devon, Plymouth and Torbay, Deborah Archer, recorded a narrative conclusion. She found Daisy died on 22 February 2022 due to an interruption in blood flow to the brain, causing significant damage and perinatal asphyxia before delivery.
Ms Archer highlighted a 'gap' in the trust's policy, where there was no clear protocol for consultants or senior midwives to attend when understaffing risks patient safety. She issued a Prevention of Future Deaths report, criticising the 'lack of adequate communication' between healthcare professionals.
In response, Peter Lewis, Chief Executive of Somerset NHS Foundation Trust, outlined a series of improvements. The Trust has now implemented a 'professional disagreement policy' to empower staff to raise concerns. It has also introduced regular 'safety walkabouts' by senior leaders and Freedom to Speak Up Guardians.
Cultural Change and 'Listening Events'
Mr Lewis stated that the Trust's maternity leaders are actively working to understand the culture across its hospital sites. 'A number of listening events were held in 2023/24 and a programme of cultural improvement efforts rolled out in response,' he said.
The Trust has also reviewed its Antenatal Foetal Monitoring Guidelines and midwife training. Additionally, it has engaged a national Equity, Diversity and Inclusion lead to undertake a culture review diagnostic. 'We remain fully committed to embedding the learning from Daisy May's death into every aspect of our maternity services,' Mr Lewis concluded.
