A coroner has found that a “series of missed opportunities” and factors at a hospital “more than minimally” contributed to the death of a two-day-old baby. Hallie-Jayne Kompaniez Thomas died at Cardiff’s neonatal intensive unit, located at the University Hospital of Wales, on August 22, 2021 after her mum Laura gave birth to her two days earlier.
A four-day inquest at Pontypridd coroner’s court examined the circumstances into the death of the infant, who became “very unwell” after her birth, experiencing issues with severe hypoxic ischemic encephalopathy, meaning a lack of oxygen to the brain around the time of her birth, which had an adverse effect on her brain.
The first day of the hearing was told how she received a series of treatments, scans and intensive care management after becoming unwell but experienced “an acute worsening and possible seizure activity” and persistently low oxygen levels. Her treatment was stopped, and Hallie-Jayne died on August 22, 2021.
On the final day of the inquest, coroner Patricia Morgan returned her conclusions. She explained how Laura, of Swansea, had a medical history presenting a high risk requiring specific arrangements and transfer to a more suitable location in readiness for delivery. However, she found there was “insufficient planning” for transfer to the delivery suite from an induction ward, “inadequate” foetal monitoring, and a delay in the delivery of Hallie-Jayne which she said “more than minimally contributed to her death”.
Ms Morgan stated that suitable monitoring and progression of delivery would have identified foetal distress earlier and may have resulted in a different outcome. The coroner returned a narrative conclusion, expressing satisfaction that the Cardiff and Vale University Health Board has taken measures to address the risks identified in this case.
Following the coroner’s findings, it is evident that there were critical systemic failures in the care provided to Hallie-Jayne and her mother, Laura. This tragic incident underscores the importance of robust planning, monitoring, and timely interventions in neonatal care to prevent avoidable complications and tragedies.
It serves as a reminder for healthcare providers to diligently assess and address risks, provide tailored care plans, ensure appropriate monitoring, and act promptly in cases where complications arise during childbirth. The lessons learnt from this case should prompt hospitals and medical professionals to review and improve their protocols to safeguard the well-being of mothers and newborns in their care.