AN inquest into the death of a month-old baby in 2018 has been delayed after new information emerged about potential ‘bad feeling’ among staff on the maternity ward at the time.
Reference to an ‘incident’ the evening before the birth of Amelia Clyde-Smith which led to ill feeling among a maternity team – the same team that was on shift when Amelia was born – was included in a statement given by a member of that team after Amelia’s death.
However, it emerged at a pre-inquest hearing this week that this reference was later removed from the statement submitted to the Viscount’s Department at the request of someone at Health.
It meant that the coroner was unaware of this potentially relevant information and only became aware of it in July this year, when Health let the Viscount’s Department know.
The relief coroner overseeing the inquest, Bridget Dolan KC, has subsequently asked the States police to gather additional witness statements and assess if there is any criminal liability.
The police are yet to finish that process.
Health is also launching an independent investigation to find out more details about the incident that led to the bad feeling among staff, whether it may have had a bearing on Amelia’s care, which Health has already conceded was not to standard, and why references to it were removed from the witness statement.
However, that investigation is yet to be commissioned and a suitable independent person to lead it yet to be selected – hence, the inquest into Amelia’s death, which was earmarked for this January, has been pushed back to April.
Health also needs time to respond to the independent investigation and take action, if required.
At the pre-inquest hearing on Monday, Ms Dolan apologised to Amelia’s parents, Dominic and Ewelina Clyde-Smith, for the delay but added that it was important that she knew more about the ‘bad feeling’ incident in order to assess its relevance to the cause of Amelia’s death, which she is charged with determining.
Amelia suffered brain damage and died in September 2018 aged one month. In 2019, Health apologised to Mr and Mrs Clyde-Smith, admitting that her death was ‘probably’ avoidable.
The apology followed an investigation by the Royal College of Obstetricians and Gynaecologists which 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.
Mr and Mrs Clyde-Smith question whether Health would have investigated their daughter’s death had they not battled for it to happen.
Another pre-inquest review hearing has been scheduled for February, before April’s full inquest.
