Coroner condemns maternity unit after death of third baby

A coroner yesterday condemned a “scandalous” hospital maternity unit over the death of a third baby in its care.

Milton Keynes General Hospital has been heavily criticised over shortages of beds and midwives following the deaths of baby girls Romy Feast and Ebony McCall.

Yesterday, its maternity unit faced fresh scrutiny after an inquest found Alex Broughton died within a day of being born after staff failed to recognise a problem with his heart.

Thomas Osborne, deputy coroner for Milton Keynes, said by failing to recognise the baby’s deteriorating heart condition during birth, staff “lost an opportunity” to speed up delivery and treat him.

The child suffered severe brain damage during birth and died on December 3 last year after being moved to a specialist unit at the John Radcliffe Hospital in Oxford.

Mr Osborne said the way Alex’s heart was monitored was a “major area of concern”.

He said: “The monitoring of his fetal heart rate during delivery failed to recognise his deteriorating condition prior to his birth and thus failed to trigger any concern for his well being that resulted in a lost opportunity to expedite his delivery and render further medical treatment.”

The coroner added that there had been conflicting evidence about how a midwife had monitored Alex’s heart rate.

He said an Oxford medical student observing the birth had given “surprising and unhelpful” evidence by saying that he could not recall what monitoring method had been used.

The inquest also heard that Alex’s parents, Lorna Howell and Matthew Broughton, received a hospital “birth congratulations” letter on the day Alex died.

Speaking after the hearing, Alex’s grandfather, Alan Broughton, branded the treatment as “a disgrace”. He added: “It would seem that serious problems continue to exist in the maternity unit.”

The criticisms are the latest in a string of scandals to hit the Buckinghamshire maternity unit in recent years.

Last year, Mr Osborne complained that midwife shortages were “nothing short of scandalous” after the death of Ebony McCall on an overstretched maternity ward.

An inquest heard that Ebony would probably have survived, had her mother, Amanda, been given a caesarean section when she asked for one. But staff were too busy and told her they would only carry out the procedure in an emergency, the inquest heard.

The scandal came despite having already been investigated over the death of Romy Feast in the same unit in 2007, who died after her heart condition was misinterpreted. Following the inquest into Romy’s death, Mr Osborne reported the hospital to the Department of Health, which prompted an investigation by the Healthcare Commission.

Earlier this year, the Care Quality Commission, the health watchdog, issued a damning report saying its maternity unit still had too few midwives and beds.

In March, Monitor, the independent regulator of NHS foundation trusts, intervened by sending in a team of clinical advisers to ensure that services are improved.

The hospital yesterday said the circumstances surrounding deaths of the two girls and Alex had been different and added that there was “nothing to suggest that any aspect of treatment or management (of Alex) … was in any material sense deficient”.

A spokeswoman for Milton Keynes NHS Foundation Trust said: “After the death of Ebony McCall and Romy Feast, we accepted mistakes had been made and we have been making significant improvements to our maternity services over the last year.

“While equally tragic, the circumstances around the death of Alexander Broughton were very different. His mother was given one-to-one care by a qualified midwife and appropriate procedures were followed.”


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