The head of midwifery at a hospital trust admitted there were “errors in communication” between midwives and the labouring mother of a baby who died at just three days old.
Rosanna Matthews was born on November 20 2020 at Tunbridge Wells Hospital in Kent. She was born without a heartbeat and after resuscitation was placed into a coma for her three days of life.
Her mother, Elena Sala, believes if she had been allowed to start pushing at 3pm when she first started to feel the urge, rather than waiting until 4.45pm under the advice of midwives, Rosanna would have lived.
The inquest into Rosanna’s death continued on Friday at County Hall in Maidstone, Kent – however, the coroner’s conclusion, which was anticipated to be received on Friday, will now not be delivered until the end of the month.
Coroner Catrina Hepburn explained the reason for the delay could not be stated in open court, addressing the family directly: “I’m sure you’re disappointed but I’m sure you would rather we cover everything as thoroughly as possible.”
During Friday’s hearing evidence was provided by Rachel Thomas, who was deputy head of gynaecology and midwifery at the time of Rosanna’s birth.
She admitted there had been “errors in communication” between midwives and Ms Sala, and explained the steps the Maidstone and Tunbridge Wells Trust which runs the hospital have taken to reduce similar events reoccurring.
In court, Ms Sala claimed midwives were “bickering” and appeared confused during her labour, while midwives claimed she had declined a vaginal examination twice – though Ms Sala says she only declined once, and its importance in ascertaining which stage of labour she was in was not properly explained to her.
Ms Thomas explained: “There were obviously some communication issues between our midwives and Ms Sala and I think we have understood that in particular vaginal examinations can cause stress and upset in many women.
“We actually now review complaints we’ve received and concerns raised about their experiences, and we’ve produced an infographic we give to women to explain some of the reasons why we might do the examination – but are very clear that everybody has the right to decline a vaginal examination and it’s very supportive in that way.
“It’s extremely important for us to take on board any learning identified in internal and external reports.
“We now have foetal surveillance consultants in place since December 2021 and foetal surveillance midwives in place since May 2020, to look at foetal heart rate monitoring, and we have increased this consultant presence on the labour ward to seven days a week from 7am until 9pm.
“We have updated our guidance so it’s easier to follow, with flow charts in place.
“We’ve introduced a masterclass for all our doctors and staff that’s very clear about what issues need to be present to do an instrumental delivery.”
Ms Thomas also said further training has been given to ensure baby growth in utero is more consistently tracked so that babies who could potentially be born smaller than average can be flagged earlier.
“We now hold regular study days where it is emphasised growth is a very important part of monitoring the baby’s wellbeing,” she added.
She added every single one of the approximately 6,000 births per year within the trust will be audited.
