Newborn died after doctor ignored three bleeps to his pager and then failed to explain why he was lateLucy Day was 'badly let down' by the NHS who missed opportunities that could have saved tragic daughter Fleur, coroner rules
04:40 GMT, 6 December 2012
09:02 GMT, 6 December 2012
A tragic baby girl survived for just 15 hours following a catalogue of blunders by hospital staff which included an obstetrician ignoring three bleeps to his pager.
A coroner ruled that mother Lucy Day was 'badly let down' by the NHS who missed opportunities that could have saved tragic daughter Fleur.
Dr Martin Voss was alerted three times by the midwife team amid growing concerns for the expectant mother.
The child was born at Cheltenham General Hospital in Gloucestershire but survived for just 15 hours after a catalogue of errors by staff
He only arrived to review her at 4.05am after initially being called at 3.15am and gave no explanation for his delay, an inquest heard.
Mrs Day gave birth to little Fleur by Caesarean section within the hour at 4.54am on December 9, 2010 at Cheltenham General Hospital.
She weighed just 5.86lbs and was very cold. She was not feeding naturally from her mother and developed both hypoglycaemia and hypothermia.
But a coroner said other staff also failed the mum as her condition didn't trigger alarm bells quickly enough and there was a delay in moving her to a special care unit.
Paediatrician Dr Haroon Mansoori, a locum who had been at the hospital for just four days, told the inquest Fleur appeared to be in 'good condition' when he examined her.
He said he was unaware of her low temperature, but had he been, would have admitted her to the special care baby unit.
'As a result of this little girl's
death, it may well be that we will avoid and prevent similar deaths in
these circumstances in the future. The NHS is rightly cherished as a favourite institution of which mostly we can be proud.'
Coroner Tom Osborne
Paediatrician registrar Dr Ka Fai Sun was also said to be lacking 'basic skills' to help when Fleur went into the Special Care Bay Unit at around 5pm. By that time her oxygen saturation levels were low.
And a consultant paediatrician was held up in traffic and did not arrive at the hospital until 6.30pm – an hour after he was called.
Fleur died two hours later at 8.30pm and pathologists were unable to determine her cause of death.
Tom Osborne, the assistant deputy Gloucestershire coroner, said hospital staff 'missed opportunities' that might have saved the baby.
He said he was referring the case to the Care Quality Commission to investigate neo-natal care at the Gloucestershire NHS Hospitals Trust.
Recording a narrative verdict, Mr. Osborne said: 'She was not recognised as small for her gestational age and at high risk of hypothermia and hypoglycaemia – or that she had signs indicating she was unwell after delivery.
'These would have warranted an early paediatric review and admission to the special care baby unit for monitoring and investigation.
'This resulted in a lost opportunity to render further medical intervention.
'As a result of this little girl's death, it may well be that we will avoid and prevent similar deaths in these circumstances in the future.
'The NHS is rightly cherished as a favourite institution of which mostly we can be proud.
'But unfortunately, as is evident from the death of Fleur, there are rare occasions when a person under the care of the NHS is badly let down.'
Mrs Day, formerly of Cirencester, Gloucestershire, but now living in China, left the two-day hearing without comment.