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A baby died after a series of system and communication failures led to a three-hour delay in carrying out a caesarean, a coroner has said.
Romy Feast died less than an hour after she was delivered at Milton Keynes General Hospital by caesarean section.
Maternity staff had told doctors Romy’s heart-beat was abnormally high and that an emergency caesarian section was needed. But despite these concerns the registrar attempted to induce the birth.
It was only when the attempt failed that Romy’s mother, Elizabeth Feast, was taken for surgery – but even then was not told she was having an emergency caesarean.
Coroner Thomas Osbourne, sitting in Milton Keynes, said the baby was clearly in danger and more attention should have been paid to the midwives, who both had more than 30 years experience in their roles.
Recording a narrative verdict he said: “The CTG (cardiotocograph) recording her heart beat was misinterpreted, with the result that an emergency caesarean section was delayed for three hours and she suffered an acute hypoxic cerebral injury.
“Her death was contributed to by both system and communication failures.”
Mr Thomas added that he would be reporting the hospital’s actions to the Department of Health and the Royal College of Nursing and Midwifery.
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