A young couple who were "delighted and excited" about the birth of their second child were left distraught after their newborn died following serious failings by medical staff.
Callum James was just minutes old and looked "perfect" when mum Ellen James was told there'd been complications during the birth, an inquest heard on Tuesday.
Mrs James and husband Chris were helpless as Callum experienced a fetal maternal haemorrhage, or in other words "massive blood loss", said Paul Bennett, acting senior coroner for Pembrokeshire.
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Mr and Mrs James attended the two-day inquest at Haverfordwest County Hall and gave evidence themselves about how they were both "delighted and excited" at the prospect of their second child being born in May 2016. There had been complications during the birth of their firstborn, Grace, and for that reason they had decided Callum would be delivered at the consultant-led maternity unit at Glangwili Hospital in Carmarthen.
While Withybush Hospital was much closer to their home in Haverfordwest the maternity unit there is midwife-led and the couple were prepared to travel the extra distance to Carmarthen to ensure the right level of care, the inquest heard.
Although Mrs James was considered a low risk with Callum she had been classed as high risk during her first pregnancy because of concerns over gestational size, gestational diabetes, and pre-eclampsia, Mr Bennett summarised. Even so, the couple wanted to ensure matters were right from the start and had additional scans to monitor Callum's development. A damning report carried out by the Public Services Ombudsman for Wales after Callum's death found a "whole host of failings" by medical staff. It said the couple would "never know" if their son could have survived.
The inquest heard how when Mrs James began to experience contractions two weeks before her due date she initially contacted Withybush Hospital. She was told to "keep matters under review". But the following morning, on May 5, Mrs James' contractions were painful rather than uncomfortable and Glangwili Hospital advised her they were signs of labour but there was "no immediate need to travel".
Mrs James didn't want to travel unnecessarily to Glangwili and attended Withybush where she described pain on the top right of her abdomen and which was disregarded as abdomen pain. As her contractions intensified she was given the choice of remaining at Withybush or travelling to Glangwili at which point the couple decided to stick with their original plan and make the journey to Carmarthen.
The inquest heard evidence from a number of witnesses including midwife Emma Lewis who led Callum's delivery at Glangwili Hospital. Ms Lewis told the inquest that "active labour" was confirmed on arrival and the contractions "appeared to be normal".
Callum's heart rate was monitored and Mrs James got in a birthing pool where midwife Ms Lewis noticed a PV bleed. Mrs James had continued to push throughout "having the urge to do so", said Mr Bennett.
The delivery team continued to monitor Callum's heart rate but were unable to tell if it belonged to Mrs James or Callum. As she waited to be transferred to the labour ward Mrs James' membrane ruptured and Callum was delivered and placed immediately on his mother's abdomen.
Mrs James told the inquest her newborn son "looked perfect" and there were no obvious signs of concern but Ms Lewis was concerned, said Mr Bennett. Callum was "pale and floppy" and steps were taken immediately to rub the baby and get his lungs working and his circulation started. Having had difficulties with daughter Grace at birth Mrs James was not unduly concerned at this stage and "naturally assumed" Callum was simply being assisted with his breathing and circulation.
Despite their best efforts, however, they were unable to do so, said Mr Bennett, and Callum died in the arms of his parents 45 minutes later. Mr Bennett heard from experts Patrick Forbes and Professor Simon Mitchell, who both agreed the medical cause of death was foetal hypovolemic shock. This is essentially a massive blood loss through his biological connection to his mother, said Mr Bennett, as evidenced by his being floppy and pale at birth, the absence of blood in the umbilical cord, and low haemoglobin levels.
He agreed that on the balance of probability baby Callum died of a foetal maternal haemorrhage. The haemorrhage was both sudden and acute and since it had occurred there was effectively little that could have saved him, Mr Bennett said, recording a narrative conclusion.
He concluded: "Callum died as a result of hypovolemic shock brought about by a an acute and severe loss of blood which occurred during the course of his delivery at Glangwili Hospital Carmarthen on May 5, 2016."
He paid tribute to Mr and Mrs James for showing "fortitude" during what he called "a very difficult inquest to hear".
Speaking after the inquest the couple said it was a relief to finally have the answer about why Callum had died. They said: "We've always needed to know the cause of death – it's been difficult not knowing what Callum passed away from. It's just nice to finally know."
They said they'd found great comfort through Tommy's Charity, which aims to find causes and treatments to save babies’ lives and provides support to those who've lost a baby. The couple travelled to Manchester to help them find answers which "helped with reassurance", they added.
"It's not something people like to talk about, losing a baby. It's something you never think about actually happening to you and we just talk about it to try and raise awareness."
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