Health board failures caused death of baby, inquest finds
A health board’s failure to deliver a baby boy in a timely manner caused his death, an inquest has found.
Jenson James Francis died on the morning of June 21st 2018 at Prince Charles Hospital in Merthyr Tydfil, just 40 minutes after being born by caesarean section.
He died of cardiopulmonary failure. The delay in delivering him meant he was exposed to maternal sepsis.
Coroner Mr David Regan cited "systemic failures" as a cause of baby Jenson’s death.
The inquest at Pontypridd Coroner’s Court heard how despite abnormal heart and movement readings at around quarter past ten on the 20th of June, it wasn’t until after 4am the following morning that a decision to deliver by c-section was made.
A senior doctor giving evidence at the inquest into the death of baby Jenson said that staff on duty at Prince Charles Hospital had failed to identify his condition deteriorating in the womb.
Dr Pina Amin, who carried out a root cause analysis of the case, said she could see abnormalities.
Dr Amin said, “Baby Jenson has not reassured me for a very long time – a number of hours at least.” She said there would be concern over Jenson’s movements and the amount of oxygen he was getting.
Dr Amin continued by saying that based on what she could see, she would have recommended a caesarean section to Jenson’s mother, Tiffany Gillard, a lot earlier.
The head of midwifery at Cwm Taf Health Board, Kerri Eilertsen-Feeney, gave evidence saying that training is in line with Welsh Government guidelines and all other health boards in Wales.
In a statement following the inquest, the family of Jenson James Francis, his mother Tiffany Gillard and Jenson’s father James Francis said: