By Sam Elliott-Gibbs
Missed opportunities like failing to deliver earlier led to the avoidable death of a tragic baby, a coroner has concluded.
Ethan Blackwell lived for just 32 hours, but would have survived if he was born by caesarian section seven hours before. He was eventually born at Royal Derby Hospital at 5.35am on May 21, 2021, but died in his mother's arms a day later. His parents, Jodie and Ben Blackwell had waited three years for an inquest’s conclusion into their son’s death.
Coroner Sabyta Kaushal concluded today that the death of the tot - who had significant brain damage and failed organs which left him gasping for air - could have been prevented. Following a three-day hearing, Miss Kaushal found that while there were numerous missed opportunities, she felt this did not amount to neglect, detailing there was “no evidence of gross failure to provide basic medical care”.
Miss Kaushal stated that a lack of involvement of the parents in the decision-making process - with no evidence that they provided informed consent in relation to c-section plans being scrapped twice at 3.28am and 5.45am - on the day of Ethan’s birth. She said: “There was a missed opportunity to deliver Ethan at that time (5.35am). If delivery had taken place at that time, or shortly after, then he would have survived.”
Miss Kaushal detailed that concerns were not escalated and that equipment dedicated to monitoring Ethan’s heart rate provided “false reassurances” to clinicians. She found that there was no documentation to show the reasoning for the c-section plans being reversed, which had followed two bradycardia – significant and sustained drops in Ethan’s heart rate. This was “not documented nor explained”, she said. “It is accepted that Jodie and Ben were not involved in the reversal decision. There is no evidence of informed consent.”
Speaking to DerbyshireLive after the conclusion, parent Jodie said: “This inquest has come after an agonising three-year wait and is just six weeks before the anniversary of our son Ethan’s death. We have waited a long time for answers but we are satisfied that the inquest has highlighted the areas where Ethan was failed and we as parents were ignored. Ethan was our firstborn son who we couldn’t wait to bring home. He should have never been an opportunity for lessons learnt or a case study in order to make improvements.
“What our baby went through should never have happened. We know he could and should have survived had he been given a c-section by 5.35am or as soon as possible thereafter. We would have had an almost three-year-old healthy little boy playing at home with his little sister. We should have been able to bring our beautiful baby boy home where we spent months making everything perfect for him. No apology will ever be enough. We miss him every single day and there will always be a huge hole in our family.
Garry Marsh, Executive Chief Nurse at the University Hospitals of Derby and Burton NHS Foundation Trust, said: "We are profoundly and deeply sorry for the tragic loss of Ethan and for the continued heartbreak that we know the shortcomings in his care have caused.
"We fully accept that we missed opportunities to deliver Ethan sooner, and we have been determined to make changes in the years since his tragic death in 2021 to make our care safer, particularly around measuring a baby's heartbeat during labour and how we involve families in decisions about their care.
"We have new heart rate monitoring equipment which tracks oxygen levels and is checked daily, and our staff training rates in this specialist area are now above the national standard with support from dedicated midwifery and doctor leads. Our clinical guidelines are up-to-date with national best-practice, and we have changed our escalation, handover and documentation practices so that they support safer and more coordinated care and better involve families in decisions.
"Whilst we know these changes cannot possibly impact on the grief caused to Ethan's family, we remain absolutely committed to continuing these improvements so that we provide safer care for every parent and baby at our hospitals."
