HEALTH chiefs apologised to the parents of a baby who died shortly after birth in the General Hospital’s maternity unit and admitted that the death was ‘probably’ avoidable.
The apology, offered in 2019, followed an investigation by the Royal College of Obstetricians and Gynaecologists into the death of Amelia Clyde-Smith in 2018.
It found that there were ‘missed opportunities with management of maternal observations’ after complications with the birth were recognised and that there was ‘an absence of a proper escalation policy’ once things started to go wrong. A report issued as a result of the inquiry made a series of recommendations, which included improving ‘candour’ with patients and developing an ‘escalation policy’.
It added that investigators could not be certain that an alternative course of actions would have resulted in a different outcome.
Parents Dominic and Ewelina Clyde-Smith said that their daughter Amelia was starved of oxygen and suffered brain damage during the ‘heartbreaking’ incident.
The couple said they ‘tried to go down the official route and do everything by the book’ after receiving the apology in 2019, but are now speaking out about the healthcare they received because they do not feel that they have got justice for Amelia.
A letter sent to the couple in April 2019, signed by chief nurse Rose Naylor and group medical director John McInerney, said: ‘We acknowledge that the intrapartum care both you and your daughter received on the day of her birth was not to the standard that all our maternity patients rightly deserve.
‘We accept that there were failings in the intrapartum care before delivery of your daughter and we offer you our unreserved apology for the care provided at Jersey General Hospital.’
The letter also references a report on the incident by the Royal College of Obstetricians and Gynaecologists, which Ms Naylor and Mr McInerney said ‘concludes that it was not possible to determine with certainty if a different course of actions would have led to a better outcome’.
They added: ‘We cannot say whether Amelia’s death was inevitable; but as we will explain, we probably could have avoided it, and for that we are deeply sorry.’
The RCOG report conclusion said: ‘There were missed opportunities in providing her with optimal care, particularly in two areas: management of maternal observations, which could have alerted medical staff to the possibility of chorlonamnlonitis, and the actions following the recognition of a pathological CTG In the second stage of labour.’
However, it added: ‘It has not been possible to determine with certainty if a different course of actions would have led to a better outcome.’
The report also makes several recommendations including the issuing of guidance concerning ‘the frequency of labour ward rounds and handovers’ and development and implementation of ‘an escalation policy to support staff at times of high work load and acuity’.
‘It is very sad and heartbreaking for us and we still can’t come to terms with this,’ Mrs Clyde-Smith said.
‘I never thought that I would be unsafe at Jersey’s hospital – you always think that the Hospital is the safest place for you to have a baby.’
She said she was admitted in August 2018 and the decision was taken to induce labour because her membrane had prematurely ruptured – however, the couple claim that there was ‘no mention’ of the risk involved with induction and Mr Clyde-Smith was advised to go home.
Mrs Clyde-Smith said she was left unattended at the ward – in significant pain – for over two hours with no midwife.
‘I was contracting every 40 seconds, I was walking around the ward trying to find someone to help me,’ she said, adding: ‘I had another patient, a pregnant woman, who actually came up to me and said “Can I help you?” because I was in such pain – I never thought I would be treated like that in the Hospital.’
Other issues, the couple said, included long wait times for an anaesthetist and a lack of a doctor when Mrs Clyde-Smith was in a ‘bad state’ during labour. They said that Amelia was born pale and ‘lifeless’.
Mrs Clyde-Smith said they had to ‘keep emailing and battling with the Hospital for them to investigate’, with Mr Clyde-Smith adding that, at one point, the couple went into the police station and ‘reported a crime of manslaughter’.
When contacted by the JEP yesterday, a Government of Jersey spokesperson said: ‘The death of baby Amelia Clyde-Smith in September 2018 was a tragic event. Health and Community Services made an unreserved apology to the family of Amelia concerning her care, in 2019.
‘The inquest into Amelia’s death is yet to be concluded and for this reason, Government of Jersey cannot comment further.’
