Baby died after hospital failings starved her of oxygen at birth

A baby suffered brain damage and died due to failings at a hospital where her mother spent hours alone in pain and suffered crucial delays, according to her family.

Dominic and Ewelina Clyde-Smith toldThe Independent their daughter, Amelia, was otherwise healthy and poor care led to her being starved of oxygen at birth.

The couple said they experienced a series of failings at Jersey General Hospital in 2018, including a lack of a doctor during a difficult labour and staff taking “too long” to resuscitate their child.

They believe Amelia suffered further harm when a ventilator was not plugged in properly during a transfer.

Amelia was left with brain damage and died aged one month after being put into palliative care.

Her parents said they have spent years trying to get justice through official channels but are now speaking out for the first time as they believe the standard of care received should be public knowledge.

“It happened nearly four years ago,” Ms Clyde-Smith says, adding: “But the whole maternity unit just failed us completely.”

She says the family will “never know” if the outcome would have been different if just one issue had not occurred.

“Maybe our daughter would be disabled, but she would still be with us,” Ms Clyde-Smith, a lawyer, said.

The 37-year-old added: “It’s just so horrible to go through. We will never know whether there was any chance for her.”

Hospital bosses have apologised to Mr and Ms Clyde-Smith for the care received and admitted delays “probably” made a difference to the outcome.

The family is sharing their story months after an independent inquiry shed light on “catastophic”maternity failings at Shrewsbury and Telford Hospital Trust, where there were more than 200 avoidable baby deaths or brain damage cases over two decades.

Donna Ockenden, who led the review, is now preparing to lead another into a Nottingham maternity scandal.

Jersey’s maternity unit was the subject of a report last year, which found it could be considered “safe” but raised concerns over women being treated with a “lack of compassion” and not supported to make informed decisions - something Ms Clyde-Smith said she experienced when she was admitted in August 2018.

She claimed she was induced without being fully informed of the risks, with her husband advised to go home, and suffered intense pain for two and a half hours - from midnight until around 2.3am - before she was able to speak to a member of staff.

The couple said there was no monitoring of the baby during this time.

Ms Clyde-Smith told The Independent she faced a “considerable” wait for the anaesthetist - the only one on shift at the time - to turn up. When they did, the epidural failed and the mother did not get any pain relief.

Amelia’s parents also believe senior medical staff should have been present during labour, given worrying heartbeat readings and Ms Clyde-Smith “not coping” with the pain and having dangerously high blood pressure.

A doctor was contacted at around 5am, but was in theatre with another patient at the time. The parents claim the doctor did not even know Ms Clyde-Smith was there.

The on-call consultant was not contacted. “At that point, when you got one doctor who’s busy on surgery, you should call another one,” Mr Clyde-Smith, 40, said.

Ms Clyde-Smith said there were several failed attempts at an episiotomy - a cut that speeds up birth - by the midwife.

“She took about 20 minutes to do it. Which actually would have probably made a difference to our daughter when she was being born,” Ms Clyde-Smith said.

She added: “And then when our daughter was born, there was problem with her resuscitation equipment. It didn’t work properly. They took too long to resuscitate our daughter.”

Amelia was born “pale and floppy” in poor condition with no respiratory effort. She was cooled - a treatment for babies who have been starved of oxygen - and sent to Portsmouth Hospital.

They believe she suffered “further brain insults” when a ventilator failed during this transfer, which reports show was due to a plug not being inserted properly, and Amelia getting 100 per cent oxygen instead.

An MRI scan at Portsmouth confirmed Amelia had severe acute hypoxic ischemic encephalopathy - brain damage caused by a deprivation of oxygen and blood flow.

“Everything concluded... she was a healthy baby developed full term, she had a perfectly formed brain. And the only reason why she was the way she was is because of the starvation of oxygen at birth,” Ms Clyde-Smith said.

The family praised the care received at Portsmouth. But Ms Clyde-Smith said: ”They couldn’t do anything. Because it was too late. All of that damage happened at birth.”

Hospital bosses have apologised to the parents for the care received in a 2019 letter seen by The Independent.

“We acknowledge that the intrapartum care both you and your daughter received on the day of her birth was not to the standard that all our maternity patients rightly deserve,” the medical director and chief nurse at the time said.

“We accept that there were failing in the intrapartum care before delivery of your daughter and we offer you our unreserved apology for the care provided at Jersey General Hospital.”

They said an expert neonatologist, who had conducted a report into Amelia’s death, told them the infant was “exposed to a potentially damaging hypoxia” from around 5am on the day of her birth.

“Taking account of all the relevant features, such as a need to involve resident medical staff earlier, the possibility of calling the on-call consultant earlier, the quality of observations taken and the management of the handover, this leads us to believe that we should have summoned help before 05.10 and Amelia should have been delivered at least 30 minutes earlier that she was,” they said.

“That probably would have made a difference to the outcome.”

A Royal College of Midwives and the Royal College of Obstetricians has also conducted a report into Amelia’s case.

It said there were “missed opportunities antenatally” in how Ms Clyde-Smith was monitored and a lack of communication meant there was “minimal involvement” of medical staff despite several risk factors.

“At the time of birth, there was no escalation to senior members of staff following the recognition of a pathological CTG pattern, which may have altered the outcome for the baby,” the report said.

The colleges said the length of staff shifts and the lack of structured handovers may have also affected care.

A Government of Jersey spokesperson said: “The death of baby Amelia Clyde-Smith in September 2018 was a tragic event. Health and Community Services made an unreserved apology to the family of Amelia concerning her care, in 2019.

“The inquest into Amelia’s death is yet to be concluded and for this reason, Government of Jersey cannot comment further.”