Video report by ITV West Country's Jacquie Bird
A couple whose baby died shortly after being born at Derriford Hospital in Plymouth are urging the maternity service to learn lessons from his death.
A pre-hearing inquest heard that Giles Cooper-Hall was delivered with just 40% of his blood in his body, and he'd been starved of oxygen for 21 minutes.
Things had gone catastrophically wrong in the hours and days before he was born, but staff on the maternity ward did not realise.
Last year, the Healthcare Safety Investigation Board (HSIB) found that baby Giles' death needn't have happened, and inexperienced and distracted staff failed to adequately care for his mother Ruth too.
Ruth's wife, Allison Cooper-Hall, told ITV News: "He was perfect. He looked exactly like Ruth, with those ginger tints and freckles on his face.
"There's not a day that goes by that we don't think of him."
This happened in November 2021, but just today it was revealed that the maternity services at Derriford Hospital have been downgraded from 'good' to 'requires improvement' by the Care Quality Commission (CQC) after an inspection in September.
The inspection found:
There were not enough staff to care for women and keep them safe.
Staff did not always assess risks to women when they were admitted to the service or attended maternity triage.
Staff did not always receive adequate training in key skills, including emergency evacuation of the birth pool and safeguarding.
There were risks of documentation being incomplete before the implementation of a new IT system.
These findings have horrified the Cooper-Hall family.
"What makes us angry or hurts us the most is that we went through a six-month independent HSIB investigation, it was really thorough and very traumatic for us," Allison told ITV News.
"17 findings, five health and safety recommendations and nothing seems to have improved over the last year, nothing's changed."
Derriford's director of maternity services Sue Wilkins said she couldn't comment on Giles' case as the inquest hearings were still underway.
But she did say that changes had been made at Derriford since the inspection.
"People who are coming in and having their care with us are coming to a unit that the CQC have acknowledged is outstanding for caring and nothing has changed with that," she said.
"Our rating for caring is still outstanding and that is reflective of the fabulous team of staff that we have in maternity.
"We've put in place a huge number of extra staff and that is ongoing. We've got even more staff, even more qualified staff coming to join us."
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