An inquest into the death of a baby has heard that he could have lived if he had been delivered sooner.
During the second day of the hearing, at Bolton Coroner’s Court, coroner John Pollard suggested the consultant who treated Rueben’s mother Laura Monks was ‘not up to the job’.
He also described the staffing situation on the maternity ward on the day Rueben died as ‘dangerous to patients’.
The court heard that consultant Mrinal Shah was told over the phone by a midwife that a foetal heart monitor, known as a CTG, showed there were abnormalities with Rueben’s heart rate.
When Ms Shah visited Ms Monks around an hour later, the CTG showed that the abnormalities were now classed as a ‘pathological trace’, the inquest was told.
That meant Ms Monks should have been given a ‘category one’ c-section, meaning the baby had to be delivered within 30 minutes, the court heard.
Instead, the inquest was told, the consultant decided Ms Monks would have a ‘category two’ section, which meant the baby would be delivered within 70 minutes.
Ms Shah let Ms Monks go for a shower, while she was said to have gone for a cup of tea.
When asked by the coroner why she allowed Ms Monks to go for a shower, Ms Shah said her patient was upset about having to have an emergency section.
Mr Pollard replied:
Ms Shah told the inquest that at the time, she was ‘not assertive enough with her patients’.
Mr Pollard then put to her:
Ms Shah accepted that statement.
Questioning why Ms Shah needed a cup of tea before going into surgery, Mr Pollard added:
Describing the staffing situation on the ward on November 19, 2011 - the day Ms Monks was admitted - Ms Shah told the inquest that she was the locum consultant, and was also ‘acting down’ as the registrar.
The senior house officer on call was a locum GP trainee who was not familiar with the hospital, she added.
Mr Pollard said:
In 2016, bosses at Wrightington, Wigan and Leigh NHS Foundation Trust admitted liability for Rueben’s death and awarded the family £40,000.
The family only discovered that the trust had carried out an investigation into their son’s death when Ms Monks called them in 2013, desperate for any more information about why her son had died.
It was only then that she was told that the hospital had carried out the investigation.
They found out the Ms Shah, who now works for The University Hospital of South Manchester NHS Foundation Trust, had been suspended while the investigation was carried out and referred to the General Medical Council, but no action was taken against her.
The inquest was told that now, families would be involved in similar investigations, particularly since the introduction of ‘Duty of Candour’ guidelines in 2014.
The inquest also heard that since Rueben’s death, staff had undergone rigorous training, including on how to interpret CTG results. Proceeding.