“It is now vital that the Trust reviews its procedures and the training of its staff in order to improve patient care for others. “We will continue to support Jay and Andrew during this difficult time to help them access the specialist support they need to try to come to terms with Freddie’s death as best they can.”
The inquest heard that Jay Whewell was transferred to Gloucester delivery room from Cheltenham Hospital due to high blood pressure around 5am on the day of delivery.
She was seen at 9:17 a.m. after a doctor-patient discussion and oxytocin was administered at 10:30 a.m. No vaginal examination was performed at this time.
She was re-examined at 11.05 a.m. by a midwife and it was decided that the drug would be given to her at 12.05 p.m. By 1:25 p.m. she had been fully dilated for two hours and 20 minutes and the use of oxytocin was discontinued as it was expected that a Caesarean section would be required.
The inquest heard only one operating theater was in use that Sunday and staff understood a second could not be opened unless there was a life-threatening situation.
The inquest was also told that the delivery room had been very busy that day and that staff and clinicians had to undertake a juggling exercise and prioritize which patients to care for. Ms Whewell was considered the lowest priority of the three mothers who had difficult deliveries.
Once inside the operating room, Dr Tomlinson said she tried to lift the baby’s head after the initial incision without success and so a midwife tried to extract Freddie through the vagina, but again without success.
Eventually Freddie was delivered by Dr. Tomlinson via reverse breach extraction at 3:54 p.m. and he was given IV fluid and at 20 minutes he was given neonatal blood.
Baby Freddie was then taken to St Michael’s Hospital in Bristol, but despite medical intervention died on May 29, 2020.
The inquest was told the hospital was also hampered by Covid-19 restrictions at the time.
Louise Roe, head of the Health Care Safety Inspectorate’s Maternity Investigation Team, said the council carried out an investigation by a team of 12 people.
She explained that among the board’s findings were that obstructive labor should have been suspected at 9:17 a.m. when the mother was seen by the team; a vaginal exam should have been performed before the administration of oxytocin, but the board concluded that the baby’s head would still have been affected without the use of the drug; the delay in admitting Freddie to the operating theater likely contributed to his head being deeply affected.
The Board also noted that a delay in obtaining neonatal blood may have delayed his resuscitation.
The Board advised on a number of security measures, including formalizing the use of the second operating theater through the use of the Trust’s risk register in the event of limited availability; training obstetrics and midwifery staff participating in local and regional training in situations highlighted by the survey and ensuring that neonatal blood is readily available.
The Trust has also been advised to ensure that local guidelines are issued regarding low carbon dioxide babies.
Ms Roe said the trust had implemented some of the recommendations and a business plan for the weekend opening of the second operating theater was before the trust’s management for approval.
The coroner said he was greatly assisted in the conduct of the inquest by solicitor Caroline Pennells for the Gloucestershire Hospitals Foundation Trust and Richard Barker for the family of the deceased.
In a joint statement after the hearing, Mr and Mrs Whewell: “We were overjoyed when we found out we were expecting Freddie and were so excited to have him part of our family.
“It’s hard to put into words the emotion of how what should have been one of the happiest times of our lives turned into such despair.
“Freddie was such a fighter until the end. Although he was taken from us far too soon, we feel so blessed that he is our boy.
“We knew investigating and hearing evidence about what happened to Freddie was going to be incredibly difficult, but it was something we had to do to have our many questions answered and to honor his memory.
“Nothing will ever make up for the pain of losing Freddie, but we just hope that by talking we can raise awareness of what we’ve been through to help other families.”
Mark Pietroni, Chief Security Officer and Chief Medical Officer of Gloucestershire Hospitals NHS Foundation Trust, said after the hearing: ‘The circumstances surrounding the death of baby Freddie are tragic and we wish to express our deepest condolences to the family.
“We are committed to learning all we can from this. The coroner was pleased with the progress made by the Trust in implementing the recommendations of the Health Care Safety Inspection Board, including the provision of a second emergency room team. We will ensure that they are integrated into our practice for the future.”
A fund set up in Freddie’s memory by his family, the Frederick Rowan Whewell Star Tribute Fund, has so far been established which has so far raised over £9,000.
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