A coroner has ruled that Article 2 was engaged at the inquest into the death of Jasper Brooks at Darrent Valley Hospital in April 2021, when he was just 23 hours old.
The extensive catalogue of errors listed range from delayed intubation and resuscitation to the misinterpretation, misrepresentation and withholding of advice given to Jasper’s parents.
Amidst a growing number of inquiries into poor maternity care, the finding that Jasper died following a series of gross failures could add weight to the campaign for a national inquiry.
In Jasper’s case, his mother Phoebe was scheduled to undergo a caesarean section after suffering a placental abruption in her first pregnancy. Despite this history, staff attending Jasper’s birth ignored Phoebe’s repeatedly raised concerns, the birth plan and protocol, and failed to carry out vital checks and seek the views of a neonatologist in a timely manner.
Opportunities to monitor Phoebe and Jasper and bring the caesarean forward were missed, even though Phoebe was bleeding excessively and suffering significant sickness and pain, whilst displaying no increase in contractions.
After birth, further failures occurred before and during Jasper’s resuscitation. The decision to move Jasper to palliative care was then made incorrectly. There were also failures in consultation when Jasper’s parents were misinformed about the care choices available to them.
At the hearing, Richard Baker KC accused the midwife present of “failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary.”
Overall, the coroner found that the failings were such that Article 2 was engaged. Jasper’s right to life had not been protected when his care was prematurely withdrawn. The Trust had failed to follow the Duty of Candour in dealing with Jasper’s parents, played down their concerns, and failed to seek and then disregarded critical advice, all whilst failing to provide even basic medical attention.
In response, the Dartford and Gravesham NHS Trust commented that “We are committed to learning from our mistakes to ensure no family has to go through this again.”
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