1. ITV Report

'Series of failures' contributed to death of newborn

A coroner has ruled a "series of failures" contributed to the death of a newborn.

Little Charlie Jermyn died at just 29-hours-old last May after contracting sepsis following his birth at home in Penryn.

After a three day-long inquest the coroner recorded the conclusion Charlie had died of natural causes contributed to by a sequence of failures in the healthcare system during the first 24 hours of his life.

On the day of his birth, mum Hayley Jermyn had been sent home hours earlier by the Royal Cornwall Hospital, who said she was not ready.

But the inquest heard had the pair been admitted to hospital, signs of the illness would have been spotted.

Dr James Gray said antibiotics would have been given and Charlie would probably have survived.

Charlie's parents Hayley and Mark outside Truro Coroner's Court Credit: ITV West Country

In a statement given by the family's solicitor, Tim Goldburn, they said they believed they had been "let down by significant system failures".

They said the hospital had failed to train and equip their midwives to recognised "red flag" signs of sepsis.

The expert evidence was that Hayley Jermyn should never have been discharged from the Royal Cornwall Hospital and that on the balance of probabilities Charlie would have survived if he had been born in hospital, or had been admitted by the first two midwives who saw him at home, or after the call to the out of hours emergency helpline if that call had been escalated to a qualified midwife.

Instead Hayley waited five hours in the busy maternity unit, only to be told she could go home in the early hours of the morning, where baby Charlie arrived suddenly and headfirst into the toilet.

Three midwives came to the house in the 30 hours that Charlie lived and although caring and dedicated professionals, none took his vital signs or his temperature until just before he died.

– Tim Goldburn from Coodes Solicitors, on behalf of Mark and Hayley Jermyn
Charlie's parents with their lawyer Credit: ITV West Country

The inquest at Truro heard that when the family did as they were advised, and sought help from an out of hours helpline, their call was handled by an unqualified maternity support worker.

That helpline was Charlie’s final safety net, and it failed.

– Hayley and Mark Jermyn

The couple said they hope "some good" will come from Charlie's death.

The single biggest issue that Mark and Hayley want to highlight to parents and health workers is the symptom of respiratory grunting as a ‘red flag’ sign of sepsis in newborn babies. Poor feeding and sleepiness are other potential warning signs.

Mark and Hayley are now seeking a personal assurance from Health Secretary Jeremy Hunt that as soon as the Coroner’s recommendations are published about the diagnosis and treatment of sepsis they are implemented in full throughout the country.

– Tim Goldburn, on behalf of Mark and Hayley Jermyn
Charlie Jermyn


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