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Health board failures caused death of baby, inquest finds

Jenson's parents, Tiffany Gillard and James Francis. Credit: ITV Cymru Wales

A health board’s failure to deliver a baby boy in a timely manner caused his death, an inquest has found.

Jenson James Francis died on the morning of June 21st 2018 at Prince Charles Hospital in Merthyr Tydfil, just 40 minutes after being born by caesarean section.

He died of cardiopulmonary failure. The delay in delivering him meant he was exposed to maternal sepsis.

Coroner Mr David Regan cited "systemic failures" as a cause of baby Jenson’s death.

The inquest at Pontypridd Coroner’s Court heard how despite abnormal heart and movement readings at around quarter past ten on the 20th of June, it wasn’t until after 4am the following morning that a decision to deliver by c-section was made.

Jenson's parents gave a statement at the inquest. Credit: ITV Cymru Wales

A senior doctor giving evidence at the inquest into the death of baby Jenson said that staff on duty at Prince Charles Hospital had failed to identify his condition deteriorating in the womb.

Dr Pina Amin, who carried out a root cause analysis of the case, said she could see abnormalities.

Dr Amin said, “Baby Jenson has not reassured me for a very long time – a number of hours at least.” She said there would be concern over Jenson’s movements and the amount of oxygen he was getting.

Dr Amin continued by saying that based on what she could see, she would have recommended a caesarean section to Jenson’s mother, Tiffany Gillard, a lot earlier.

The head of midwifery at Cwm Taf Health Board, Kerri Eilertsen-Feeney, gave evidence saying that training is in line with Welsh Government guidelines and all other health boards in Wales.

In a statement following the inquest, the family of Jenson James Francis, his mother Tiffany Gillard and Jenson’s father James Francis said:

There is not a day that goes by when we all don't think of Jenson. Trying to come to terms with what happened and Jenson's death has been incredibly traumatic.

We put our faith in health professionals but it is difficult not to think that we were badly let down by those who were supposed to help us.

While we remain absolutely heartbroken that Jenson is no longer with us, he will always be part of our family. We will never forget him.

We just hope that the Health Board learns lessons as we would not want any other family to suffer the pain we face daily following Jenson's death.

– Family statement

We are deeply sorry for the significant failings in the care provided to baby Jenson and Ms Gillard. Losing a baby is absolutely devastating and we offer our sincere apologies for the distress and trauma that Jenson’s parents and their families have experienced, and continue to go through.

The accounts from some of the women and families who have been in our care are heartbreaking and our thoughts are with all those who have experienced such a tragic loss.

We are determined to do everything we can to put things right in our maternity services and we promise to learn from these devastating experiences to make things better for the future.

– Allison Williams, Chief Executive of Cwm Taf Morgannwg University Health Board