Baby Archie Batten died due to 'natural causes contributed to by neglect' at Kent's QEQM hospital
The death of a newborn baby, hours after his mother was turned away from a maternity unit, was caused by "natural causes contributed to by neglect", an inquest has heard.
Rachel Higgs attended the Queen Elizabeth Queen Mother Hospital (QEQM) in Margate, Kent on the morning of September 1, 2019, but was refused a bed and sent home at 2pm because the maternity unit was full.
She was then seen at home by four midwives for four hours before she was admitted by ambulance to the QEQM at 10pm, when it was realised she was an emergency case.
Archie Batten was born but died shortly afterwards, and the cause of death was recorded as hypoxic brain injury caused by prolonged labour.
The inquest into Archie’s death was concluded on Friday, June 10, in Maidstone by coroner Sonia Hayes.
Ms Hayes found that if Miss Higgs had not been turned away from the QEQM day maternity unit, and if Archie had been born at any time prior to 10.15pm, he would have survived with no neurological injury.
Ms Hayes said: "There were a number of missed opportunities to note complications in Archie’s mother’s labour over a 10-hour period, and with observations and foetal heart monitoring.
"Rachel was in a dependent position due to being in labour, and was reliant on the judgment, care and treatment of clinical professionals at the hospital and midwives who attended her at home.
"Archie, as a baby in utero, was entirely dependent on others for his survival, and it is hard to conceive of a patient more vulnerable and in need of care.
"Decisions made in respect of Rachel in labour directly impacted upon Archie.
"I find there were multiple missed opportunities to render care to Rachel and as a consequence to Archie, that were obvious and not only would have made a difference but would have prevented the death of Archie."
However Ms Hayes did not issue any Section 28 "prevention of future death" regulations against the East Kent Hospitals University NHS Foundation Trust, which runs the hospital, concluding the Trust had learned "a great many lessons" since Archie’s death.
She also did not issue any regulations against any of the midwives involved in Archie’s care.
Ms Hayes explained: "These failures amounted to gross failures to provide basic medical treatment and that there was treatment available at hospital on September 1, 2019.
"I must say to the Trust I was significantly concerned about many of the issues I heard.
"I am satisfied on the evidence I have heard the Trust has taken the death of Archie Batten extremely seriously and have put a great many changes in place, of which I heard much detailed evidence.
"Without that I would have made a number of regulation 28 reports. I am satisfied in this case that is not necessary."
At the conclusion of the inquest, Tracey Fletcher, Chief Executive of East Kent Hospitals, said: "On behalf of the Trust, I apologise unreservedly to Archie’s parents and family for Archie’s death.
"We fully accept the Coroner’s findings and conclusion today and we are deeply sorry for the failings in the care provided to Archie and his family in September 2019.
"We have made, and continue to make, changes and improvements to the quality and safety of our maternity service.
"Since Archie’s death, we have made changes to how we care for women and babies during a homebirth and to how we provide the service when the hospital maternity units are busy.
"The lessons from Archie’s death, and the findings of the independent investigation into our maternity service being led by Dr Bill Kirkup, will be built into our continued improvement, to ensure we provide high-quality maternity care for families in East Kent."