Watch as Giles' parents speak to ITV News about the coroner's report
A coroner has highlighted a series of "missed opportunities" which could have contributed to the death of a baby at Derriford hospital.
Giles Cooper-Hall was just 16 hours old when he died.
The coroner today (Friday 2 February) summed up how his mother's care plan was not followed, and while it may not have made a difference in saving Giles' life, she said: "we do not know what could have been".
After the verdict, mothers Allison and Ruth Cooper-Hall shared a statement saying the "hopes and dreams we had on the birth of our son Giles have been completely shattered".
Ruth Cooper-Hall was 41 weeks into her pregnancy when she experienced reduced foetal movement.
Senior doctor, Dr Alexander Taylor, drew up a care plan which stressed the importance of closely monitoring her baby's heart rate.
However, the plan was not communicated properly when she was induced a week later.
Other errors included delays in sending Ruth to the delivery suite as well as emergencies not being declared when baby Gile's heart rate could not be detected.
It was nearly 15 minutes before a senior obstetrician was called.
In evidence, Dr Taylor said had there been continual monitoring of Giles' heart rate, they could have plotted a decline and potentially acted earlier.
He also said a midwife should have spotted a significant reduction in his heart rate and described being "incredulous" when he arrived in the delivery suite as Giles was born.
The coroner surmised the care plan was not handed over and there were periods of "approximately 90 minutes" where monitoring was not as regular as it should have been while baby Giles' heart rate continued to decline.
There was also a chance to deliver Giles 14 minutes sooner than when he was born.
The coroner said even with all these missed opportunities it was "unlikely to have changed the outcome" but "we do not known what would have been" if baby heart rate monitoring had followed the care plan and local and national guidelines.
The narrative conclusion found Giles Cooper-Hall died from severe hypoxic ischaemic encephalopathy caused by placental abruption which occurred in absence of continuous CTG (baby heart rate) monitoring.
It follows similar findings from a report by the Healthcare Safety Investigation Branch (HSIB) which uncovered a string of errors in the maternity care.
In a statement share outside Plymouth Coroner's Court, Giles' parents said: "A catalogue of systemic problems and issues that when combined have led to the tragic death of our baby boy.
"This is not the first time something like this has happened and sadly unless more steps are taken it will not be the last."
"Nationally the NHS is in dire straits.
"Our tragic experience is a sign of a tired worn out system in need of serious investment, overhaul and support for the future."
"We are here today not only representing Baby Giles but every family that has suffered the death of their child in similar circumstances.
"This devastating tragedy has ignited a small light glowing which is getting brighter..
"We want the death of baby Giles and the findings of the investigation and inquest to be the start of hope where similar failings will not happen again, and any other families will not have to suffer the same tragic loss we have."
Sue Wilkins, the director of maternity services, complimented the "dignity and poise" of Mrs and Mrs Cooper-Hall saying it has been "an incredibly sad couple of days for us all."
"I think the coroner has done exactly what I expected her to do and exactly what we as a trust expected her to do, and that is agree in its entirety with the HSIP Report.
"There were five safety recommendations and I remain confident that we responded to those in a timely way, and we've put appropriate actions in place."
Those recommendations were:
The Trust to support staff to complete a risk assessment, which includes review of the records, at every point of handover of care to enable recognition of a mother’s risk status.
The Trust to ensure that staff are supported, prior to deciding if intermittent auscultation (listening using a hand-held Doppler) is the appropriate method of monitoring, that a risk assessment is undertaken.
The Trust to ensure that intermittent auscultation is undertaken and documented in line with local and national guidance. When staff are not able to fully comply with guidance, they should be supported to request help to ensure there is adequate foetal monitoring in labour.
The Trust to ensure that clinical staff are aware that pink amniotic fluid and or blood-stained amniotic fluid should be recognised and documented to aid planning of further care.
The Trust to ensure that staff recognise when a foetal heart rate cannot be heard or there is a suspected bradycardia that immediate escalation occurs and an emergency is declared.