A baby died at just 15 hours old after maternity staff in Plymouth repeatedly missed chances to intervene to save his life, an investigation has found.
Giles Cooper-Hall showed no signs of life when he was born at Derriford Hospital.
A report by the Healthcare Safety Investigation Branch (HSIB) has now uncovered a string of errors in the maternity care his mum, Ruth Cooper-Hall, was given.
Ruth, who was 37 when she gave birth to Giles, went to the hospital after experiencing reduced fetal movement when she was 41 weeks pregnant.
She was sent home with the understanding the team "were not concerned at all", according to the report.
But the investigation found medical staff failed to carry out proper checks because the maternity unit was "busy".
Five days later, Ruth was induced following a routine scan but a senior doctor's advice the baby's heartbeat should be continuously monitored was not passed on to staff.
During Ruth's labour, clinicians became unable to hear Giles' heartbeat but investigators found the urgency of the situation "was not recognised by the team".
Just shy of half an hour after concerns about his heartbeat were raised, Giles was born showing no signs of life.
Doctors worked for 20 minutes and were able to resuscitate him, but his brain function had been impacted and he died 15 hours later.
The investigation report released today (10 May) highlighted "ineffective communication and handover" between Ruth's team. It added the “multiple tasks” carried out by the responsible clinician acted as a “source of distraction” and stopped vital information about monitoring from being passed on.
Investigations also found new staff coming on duty failed to check Ruth's written records, so she was wrongly treated as a routine case.
As such, Giles' heartbeat was only checked intermittently and without the recommended equipment.
The report says: “Had the full plan of care been handed over between the clinicians caring for the mother, there may have been a different outcome for the baby."
What the hospital has said
A spokesperson for University Hospitals Plymouth NHS Trust said: “May we reiterate our most sincere condolences to the family on the sad loss of their son, Giles. The pain and distress they have experienced is immeasurable and our thoughts are with them.
"We would like to reassure people that all the safety recommendations stemming from the investigation will be fully implemented as part of our commitment to foster a culture of learning, development and improvement within the maternity setting.
"Since the advent of the Healthcare Safety Investigation Branch (HSIB) in 2018, our maternity department has welcomed the opportunity to participate in this national programme of high quality, independent and family focused reviews into maternity care. We would like to extend our gratitude to the investigating team for their support of both the family and the staff involved.
"We would like to thank the Cooper-Hall’s for the opportunity to be involved with the family and maintain an open dialogue whilst the investigation has progressed; explaining how we will develop services reflective of the HSIB findings.”