Report finds maternity staff at Plymouth's Derriford Hospital missed chances to save baby's life
Giles Cooper-Hall was only 16-hours old when he died in October 2021
Last updated 11th May 2022
A new report has found that a baby died after repeated missed chances from maternity staff at Plymouth's Derriford Hospital.
Giles Cooper-Hall was only 16-hours old when he passed away in October 2021.
The Healthcare Safety Investigation Branch (HSIB) made 18 overall findings in their report, with five safety recommendations made to University Hospitals Plymouth NHS Trust.
Giles' mother - Ruth Cooper-Hall - had alerted staff at Derriford Hospital that she was experiencing reduced baby movements when she was 41 weeks pregnant. She was discharged home following a review.
However, the report stated that Ruth's checks were only "partially complete", with the unit said to be "busy" at the time of her admission.
Five days later, she was induced with the advice that the baby's heartbeat should be monitored continuously.
The HSIB investigation revealed "oversights" in the care of Ruth and that her risk factors were "not recognised" and "not communicated".
It also states that a "loss of situational awareness" led to the emergency call bell not being activated when Giles' heart rate could not be heard - delaying the involvement of senior management.
The time interval between the first concerns relating to the baby’s heart rate and delivery was 29 minutes.
The report also discovered occurrences where "valuable information" was lost at handovers between members of the team providing care to Ruth, resulting in not all staff having the same information and the content of the information shared varying from person to person.
The HSIB said that, "had the full plan of care been handed over between the clinicians caring for the Mother there may have been a different outcome for the baby".
Ruth's wife, Allison Cooper-Hall, said a life was cut short due to "local and national guidance not being met":
"We didn’t get to come home with Giles due to numerous failings in care.
"So many opportunities for things to have been done differently from reading our HSIB investigation report. We need answers."
It comes after the Ockenden report, which found a string of "repeated failures" into the maternity care provided at Shrewsbury and Telford Hospital NHS Trust.
A spokesperson for University Hospitals Plymouth said: "Since the advent of the Healthcare Safety Investigation Branch (HSIB) in 2018, the Maternity Department at University Hospitals Plymouth has welcomed the opportunity to participate in this national programme of high quality, independent and family focused reviews into maternity care.
"We would like to extend our gratitude to the investigating team for their support of both the family and the staff involved.
"All the safety recommendations stemming from the investigation will be fully implemented as part of our commitment to foster a culture of learning, development and improvement within the maternity setting.
"Most importantly, we would like to thank the Cooper-Hall’s. We have been honoured to have the opportunity to be involved with the family and maintain an open dialogue whilst the investigation has progressed; explaining how we will develop services reflective of the HSIB findings.
"May we again reiterate our most sincere condolences upon the sad loss of their son, Giles. The pain and distress they have experienced is immeasurable."