Calary Fern Davis · Prevention of Future Deaths report

A Coronial investigation was commenced on 16th January 2018 into the death of Calary Fern Davis. The investigation concluded at the end of the inquest which I conducted on 6th – 8th February 2019. The conclusion was a narrative conclusion and the medical cause of death was 1a. Hypoxic Ischaemic encephalopathy

These were recorded as :-

Calary Davis was delivered by emergency Caesarean Section on 31st December 2017. She had suffered a period of acute fetal bradycardia which caused hypoxic ischaemic encephalopathy resulting in very serious damage to her brain. Her mother, ████████, had been admitted for induction on 28th December 2017, but that induction had not proceeded normally down the induction clinical pathway. ████████ had received no planned obstetric review during the course of her admission, and no obstetrician had discussed her care with her. The Cwm Taf University Health Board accept that there were a number of shortcomings in her care. Had ████████ proceeded to Artificial rupture of membranes in accordance with the appropriate clinical pathway, it is likely that Calary would not have suffered hypoxic ischaemic encephalopathy and would have survived.

The narrative conclusion which I returned was:

Calary Davis died as a result of hypoxic ischaemic encephalopathy which arose from fetal distress and bradycardia to which she was subject within the hour prior to emergency caesarean section. It is likely that she would have survived if, during her admission for induction, her mother had proceeded to Artificial rupture of membranes in good time in accordance with the appropriate clinical pathway.

The Inquest focused upon:-

a. The fact that ████████ had received no planned obstetric review during her admission 28 – 31 December 2017 and had no clear care plan
b. She spent an unacceptably lengthy period of time awaiting artificial rupture of membranes (ARM)
c. There were opportunities for ████████ to have been progressed down the induction pathway, which were missed.
d. Calary Davis was an otherwise healthy baby who would have survived had her mother been treated in accordance with the induction pathway

(1) The action plan annexed to the root cause analysis remained incomplete. It is understood that this arises in part from the merger of the maternity services of the Royal Glamorgan and the Prince Charles Hospitals.
(2) It was accepted at Inquest that the merger of the maternity units of the two hospitals, while potentially creating a future single centre of expertise, does risk causing a period of institutional stress to maternity services which have exhibited some significant shortcomings.
(3) There is a review of 43 such cases which was said to be considering them individually rather than analysing common themes and trends.
(4) In ████████’s case, proceeding to ARM would have been possible but there was a culture in the unit not to perform it at night
(5) There was a reluctance from mid ranking midwife staff to challenge decisions made by the labour ward coordinators
(6) Decisions by those coordinators were made without full information as to the clinical needs of the patients awaiting transfer to the labour ward
(7) There was a poor standard of safety briefing, provision of information on patient handover and multi-disciplinary team assessment
(8) There were insufficient staffing levels, despite which the escalation policy was not used.
(9) There was a lack of band 7 midwife and obstetric team leadership.