Death of a new-born baby Zac changes face of midwifery
THE death of a newborn infant following "shortcomings" during delivery has changed the face of midwifery in Cornwall, an inquest has heard.
Zac Bosworth died at the Royal Cornwall Hospital in Truro (RCH) five days after being born in an ambulance outside Helston Birthing Centre.
The Royal Cornwall Hospitals Trust (RCHT) said following an investigation it had dismissed the midwife involved, referred her conduct to the Nursing and Midwifery Council (NMC) and changed its midwifery procedures.
An open verdict was recorded at the inquest in Truro on Thursday, which heard that Zac's mother Gemma Bosworth, from Falmouth, arrived at Helston Birthing Centre on October 24 last year at 7pm.
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As she was being transferred to the Royal Cornwall Hospital at 4.55am in an ambulance, baby Zac started to arrive and lead midwife Elizabeth Wiles told the hearing she decided to return to the Birthing Centre to collect equipment to assist the delivery.
At 5.36am Zac was born in the ambulance outside the unit, but was not breathing.
Mother and son were taken to the RCH, with Zac receiving assistance to breathe. When he arrived at the hospital Zac had a breathing tube inserted and was given intensive care, but died on October 30.
Cornwall Coroner Emma Carlyon said she agreed with the cause of death reported after a post-mortem examination, severe hypoxic-ischemic brain injury, a result of a lack of oxygen and blood to the brain.
Ms Wiles was subsequently dismissed and the NMC imposed a 12-month interim suspension order from February 28 after she failed to appear at the interim order hearing.
An NMC spokesman said its investigation was continuing.
The changes introduced by the RCHT as a result of Zac's death include better record-keeping during transfers and a review of the assisting midwife's role.
Birthing units across the county also now have 'grab bags' containing standardised equipment for midwives to take during transfers.
Jan Walters, divisional nurse for women and children's services, told the inquest the trust was "deeply sorry" for the "shortcomings in care" during Zac's delivery.
"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," she said. "The midwife was subsequently dismissed and her conduct referred to the Nursing and Midwifery Council.
"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."