Investigation and inquest
On Ninth April 2019 I commenced an investigation into the death of Harrison Colin Hassall aged 2 Days. The investigation concluded at the end of the inquest on Ninth March 2020. The conclusion of the inquest was:
Natural causes
The cause of death was established as:
I a Hypoxic ischaemic encephalopathy
I b Delayed delivering
I c
II
Circumstances of the death
Harrison Hassall was born pre-term and breech at the Leicester Royal Infirmary on 12th January 2019 following delayed delivering contributed to by the failings of healthcare professionals upon whom he was dependent. As a result, he sustained brain damage and died peacefully on 14th January 2019 at the hospital with his parents and family present.
Coroner’s concerns
It was highlighted in evidence that midwives may be permitted to work in the community too soon after qualifying and therefore may not have enough experience. The University Hospital of Leicester NHS Trust have indicated that they will be reviewing the appropriate Grade that a midwife should have attained before taking up a community post. This is not a matter that is relevant to only Leicester.