Baby died at Tameside Hospital due to neglect and gross failure in treatment, coroner concludes

The death of a baby boy just a day after he was born was caused by hospital neglect and gross failure in his treatment, an inquest has found.

Luca Yates died at one-day-old following a severe brain injury due to a lack of oxygen at Tameside General Hospital.

His mum Nicole Ditchfield told an inquest into his death, at Stockport Coroner's Court that she was made to feel like she was 'bothering' the midwives when she phoned the hospital in labour.

She had made numerous calls to the hospital, in January 2022, when she was in labour but was not properly diagnosed and even when she attended in person, was told to go home and wait.

Coroner Chris Morris said "cognitive bias" on the part of midwives might have occurred at this stage - meaning Nicole's symptoms did not fit with their sense of what going into labour involved.

Mr Morris also criticised the Hospital's system for recording telephone calls as "inherently unsafe".

He said the absence of a safe system to record a patient's signs and symptoms contributed to a gross failure to provide medical attention.

Once Miss Ditchfield was admitted, she said staff struggled to detect her son Lucas' heart beat.

She told the court how she cried when she was told she needed an emergency Caesarean section and recalled staff 'rushing around'.

Her partner, Jack Yates told the inquest he remembered 'people running round Nicole in a manic fashion' after the C-section and that everyone left the room and he was left 'not knowing what was happening'.

Because of a problem with Nicole's placenta, Luca had been starved of oxygen whilst still in the womb and he was born with brain damage. He was also struggling to breathe.

Staff tried to resuscitate Luca and he was given oxygen, but instead of being fed 100% oxygen he was given just 21%.

The coroner concluded this failure did contribute to Luca's death.

Luca died the day after he was born.

Giving his conclusion, Coroner Morris said he found Luca's death was contributed to by neglect, defining it as "a gross failure to provide basic medical attention".

He said he will be sending a report to prevent future deaths to the President of The Royal College of Paediatrics and Child Health.

Karen James OBE, Chief Executive of Tameside and Glossop Integrated Care NHS FT, said: “We express our sincere and heartfelt condolences to Nicole and Jack for their loss of baby Luca.

"It is clear from our internal investigation and the independent Healthcare Safety Investigation Branch [HSIB] investigation, together with the evidence given in court, that there were missed opportunities in the care and treatment of Nicole and Luca.

“As an organisation, we are committed to learning and have made several improvements since Luca’s death in 2022, although we recognise this did not change the outcome for Luca, Nicole and Jack.

"On behalf of the organisation, I would like to express our profound apologies to Nicole, Jack and their families.”