The county’s most senior coroner has blasted a Norfolk hospital following “missed opportunities” to save a newborn baby’s life.
Phoebe Whitlock-Jones died at just one-week old after being born at 33 weeks and five days at the Queen Elizabeth Hospital in King’s Lynn last May.
She was transferred to the Norfolk and Norwich Hospital when she was 28 hours old.
It was here she took her last breaths with her parents by her side, passing away on June 3, 2023.
A three-day inquest into her death took place at Norfolk Coroner’s Court.
During the inquest, live evidence was given by members of the QEH's maternity team and questions were asked about the care mother Natasha Whitlock received.
Phoebe was Miss Whitlock's fourth child - with two of her first three born prematurely without complications.
Due to this, she was under consultant-led care.
The court heard how Miss Whitlock, of Barroway Drove in Downham Market, was admitted to the QEH on May 22 with contractions.
Following examinations and monitoring, she was diagnosed with oligohydramnios, a deficiency of amniotic fluid.
She was advised to stay in hospital but felt she had no other choice but to self-discharge on May 23 due to having no childcare in place for her other children.
She agreed to return the following day on the morning of May 24, which she did, and a plan was put in place for outpatient management.
On May 27, she began having contractions again and returned to the QEH.
The registrar requested a continuous cardiotocography (CTG) to monitor the baby's heartbeat.
Unfortunately, this was not carried out due to Miss Whitlock needing the toilet and staff being unaware of a portable option.
On her return, the CTG had become “suspicious”, and an ultrasound scan was commenced showing bradycardia, a slower than typical heartrate, of the baby.
An emergency caesarean section was carried out and Phoebe was born at 10.55am “pale and floppy”.
Mrs Lake said: “There were missed opportunities to identify and promptly act upon abnormal CTG findings, which was exacerbated following an interval in the CTG scan being caried out and by a pulse oximeter not being replaced immediately following that interval [of going to the toilet].”
The baby girl was taken to the N&N the following day but died on June 3 after suffering from severe hypoxic-ischemic encephalopathy (HIE) due to her premature birth and her mother having suffered a prolonged rupture of her membrane.
HIE occurs when the brain does not receive enough blood and oxygen.
Mrs Lake added: “An internal review carried out by the hospital refers to prompt identification and intervention, which could have resulted in earlier delivery with a probable improved outcome for the baby.”
She recorded a brief narrative conclusion, stating that “following pre-term rupture of membranes, phoebe was born with severe HIE and died seven days after birth.”
An investigation by the QEH into her death regarded it as “very serious” and have taken many steps with the view to prevent future deaths.
The coroner requested that the hospital update her later in the year following further planned training.
- To pay tribute to a loved one, email norfolkobituaries@newsquest.co.uk
- To read all obituaries and tributes join the Facebook group Norfolk's Loved & Lost.
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