THERE were “serious shortcomings” in the care of Amelia Amber Sweetpea Clyde-Smith, a senior health official has said after an inquest concluded that neglect contributed to the 33-day-old baby’s death.
Chris Bown, chief officer of Health and Community Services, apologised “unreservedly” to Amelia’s parents and said that “significant improvements” had been made in maternity care since the death.
A five-day inquest concluded on Friday, with Coroner Bridget Dolan highlighting “failings” by the midwifery team.
Amelia was born at the Hospital on 19 August 2018 and flown to Portsmouth immediately afterwards for emergency treatment.
She was flown back to the Island where she received palliative care until her death on 21 September.
The Coroner said: “There had been a number of shortcomings in the management of the labour and unwanted delay in Amelia’s delivery.
“I find that these failings in the midwifery team were neglect.”
The causes of Amelia’s death were found to be bronchial pneumonia and the medical condition hypoxic-ischaemic encephalopathy – brain damage caused when not enough oxygen reaches a baby’s brain before or shortly after birth.
The Coroner said: “The development of ischaemic encephalopathy had been contributed to by neglect when on the labour ward.”
Among the failings, she mentioned that cardiotocography, which is used in pregnancy to check the wellbeing of babies in the womb, was not monitored and reviewed properly.
She also said that the labour ward co-ordinator was unaware of Amelia’s mother’s progress, and that the consultant obstetrician should have been called to the ward promptly.
She added that failure to deliver Amelia sooner “left her exposed to a prolonged period of hypoxia”.
In a statement following the inquest, Amelia’s mother, Ewelina Clyde-Smith, said: “We are grateful for the Coroner’s finding of neglect.
“Though the pain of losing Amelia remains, the fact that the circumstances of her death have been acknowledged gives us reassurance.”
Senior health officials previously apologised to Ewelina and Dominic Clyde-Smith after admitting Amelia’s death was “probably” avoidable, following an investigation by the Royal College of Obstetricians, which found there had been “missed opportunities”.
Chris Bown, chief officer of Health and Community Services, yesterday accepted there had been “serious shortcomings” in Amelia’s care and said: “Once more we would like to extend our deepest condolences to Amelia’s parents and to apologise unreservedly for these failings.
“We are deeply sorry for the pain and suffering that Amelia, her parents and her wider family went through.”
He added: “Amelia died almost six years ago, and the Government of Jersey accepted liability for her death some time ago.
“Since then we have made significant improvements to maternity care in Jersey, including the appointment of a new permanent director of midwifery with significant experience of senior midwifery leadership, additional consultants and midwives and more training in cardiotocography.
“We are constantly striving to improve maternity services in Jersey in order to make them as safe as possible for mothers and babies, but we are not complacent, and we continue to work closely with all the families who use our services to find ways of making further improvements.”
He added: “We will now carefully review the coroner’s findings and will ensure that if any further action or learning is required this will be properly investigated and addressed.”
