Death of baby Zac sparks changes to midwifery
THE “TRAGIC” death of a new-born baby following “shortcomings in care” during his delivery has changed the way midwives practice in Cornwall, an inquest has heard.
Zac Cadman Bosworth died at Royal Cornwall Hospital Treliske (RCHT) after being born in an ambulance outside Helston Birthing Centre five days earlier.
Following an investigation into what it described as a “tragic event”, the hospital dismissed the midwife and introduced a number of changes to midwifery procedures.
Divisional nurse for Women and Children’s Services, Jan Walters, told the inquest it was “deeply sorry” for the “shortcomings in care” during baby Zac’s delivery.
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She added: “A thorough investigation...found that the midwife did not follow the correct procedures during labour and the transfer to the maternity unit at the Royal Cornwall Hospital.
“The midwife was subsequently dismissed and her conduct referred to the Nursing and Midwifery Council (NMC).
“Since this tragic event all of the recommendations from the investigation have been put in place and mothers-to-be can be confident in the high standards of care they will receive at our birthing centres.”
An open verdict was recorded into the death of Zac Bosworth, from Falmouth, at the inquest on Thursday.
His mother, Gemma Bosworth, arrived at Helston Birthing Centre on October 24 at 7pm, the inquest heard.
As Ms Bosworth was being transferred to RCHT at 4:55am in an ambulance, she went into labour.
Lead midwife Elizabeth Wiles told the court she then decided to return to Helston Birthing Centre to collect some equipment to assist with the birth.
At 5:36am, baby Zac was born in the ambulance outside the birthing unit, but was not breathing.
Ms Bosworth and baby Zac were then taken to RCHT, while the new-born was given assistance to breath.
When he arrived at the hospital he was incubated and given intensive care, but died five days later on October 30.
Cornwall Coroner Emma Carlyon said she agreed with the cause of death reported at the post mortem as “severe hypoxic-ischemic brain injury” – a result of lack of oxygen and blood to the brain.
The midwife who delivered baby Zac, Elizabeth Wiles, was subsequently dismissed by RCHT.
The NMC imposed a 12-month interim suspension order from February 28, 2013, after Ms Wiles failed to appear at the interim order hearing.
An NMC spokesman said: “Interim orders do not indicate guilt. At this stage, the facts of the case have not been found proved.
“It is imposed to restrict someone’s practice whilst an investigation is ongoing.”
The changes introduced to midwifery practice include improved record keeping during transfers and a review of the assisting midwife’s role.
Birthing units across the county also now have ‘grab bags’, with standardised equipment, for midwives to take with them during transfers.