7BR Member Richard Baker represented the family of Clay Wankiewicz, a baby who died 22 minutes after he was born, in an inquest. An investigation into Clay’s death found that he died from skull fractures caused by attempted forceps delivery and release of a deeply impacted head at caesarean section.

Senior Coroner Nicola Mundy made a finding in her report that “there had been a failure to attach sufficient weight to factors which should have called into question the appropriateness of advice encouraging any continuation of the efforts to push and a failure to engage obstetric input at an earlier stage.” She highlighted that confirmation bias was a factor in Clay’s death, making a recommendation for the need for awareness of confirmation bias.

Coroner Mundy was critical of Doncaster & Bassetlaw NHS Foundation Trust stating “a number of the members of staff who gave oral evidence during the inquest failed to appreciate the meaning and significance of confirmation bias, and the importance of being open minded” and that [t]here appeared to be a lack of awareness of the importance of viewing all clinical parameters etc objectively, and also the importance of looking at the overall clinical picture and wider circumstances in determining the best care pathway.”

She recommended that action be taken and the Trust must respond no later than 18 November 2021.

The case has been reported on BBC news, read more here.


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