I was breastfeeding my baby when I noticed his feeding slowed – minutes later he was pale and floppy
A BABY boy died because midwives ignored safety guidelines on the day he was born, a coroner has ruled.
Little Olly Vickers suffered catastrophic brain damage after two staff members left him alone during his first breastfeed.
One worker was repairing mum Emma Clark’s tears while the other worked at a computer when they should have been supervising.
The “neglect” on September 13, 2021, led to Olly’s death five months later on February 6, 2022, an inquest concluded.
Coroner Peter Sigee said: “There was a gross failure to provide basic medical attention to Olly while he was in a dependent position between 7.55am and 8.40am.
“This brain injury caused Olly to be unwell and it more than minimally contributed to his death.
“Olly would not have died when he did if this neglect had not occurred.”
Emma and her partner Michael were “full of joy and excitement about the future” following the birth of their first child at Royal Bolton Hospital, Greater Manchester, two years ago.
But things took a turn when the mum tried breastfeeding her son for the first time.
Emma noticed Olly’s breathing change, but neither of the midwives caring for them came to investigate.
One simply told her that the newborn would move himself if he was uncomfortable.
As Olly’s feeding slowed, Emma again asked if he was OK and the midwife repairing her tears lifted her head and said he was just asleep and this was normal.
Both ignored safety guidelines by leaving the baby unobserved.
They should have waited until Olly had been fed and been placed in a cot or with his father before attempting to stitch Emma.
The new mum also required pain relief for the stitches on her grade two tears, and NHS guidelines state this should not be given while a mother is holding her baby.
A previous investigation by the Healthcare Safety Investigation Branch found that the midwives felt under pressure to ensure Olly had a breastfeed within an hour of his birth.
As a result of the failure to monitor him, they did not notice when his position changed and his airways became obstructed.
When the midwife finished repairing the tears, she took Olly from Emma and found him to be pale and floppy.
The emergency team was called and while they could not resuscitate Olly, they managed to get oxygen into him via a ventilator.
He was then taken to the neonatal intensive care unit and remained seriously unwell.
An MRI scan of his brain revealed severe damage, and Emma and Michael were told that he was unlikely to live a long life.
Olly was in hospital for 22 weeks before he was allowed home.
He tragically died when he was just five months old.
Words cannot describe the pain of losing him, it’s there every minute of every day.
Emma Clark
Emma, from Little Lever in Bolton, said: “Olly was so strong and brave throughout his short life.
“He was such a funny and loving baby who filled our hearts with love.
“We will always treasure the memories we made with our precious boy.
“Words cannot describe the pain of losing him, it’s there every minute of every day.”
She added: “For this to be avoidable if all the guidelines had been followed compounds everything.
“We question whether if we’d gone to a different hospital on a different day Olly would still be here.
“We want to raise awareness of the need to listen to parents, to follow the guidelines, which are there for a reason, and to ensure staff are trained in the importance of these issues.
“Olly was our world and losing him is something we will never fully recover from.
“Lessons being learned from his death is the only hope we can cling on to.”
FAMILY’S HEARTACHE
The NHS had already admitted that the negligence of the midwives caused the child to suffer catastrophic brain damage and later die.
Jodie Miller, a partner at law firm JMW who is handling Emma and Michael’s legal case against Bolton NHS Foundation Trust, said: “This is a harrowing case and has taken an unimaginable toll on Emma and Michael.
“We feel a finding that Olly’s death was contributed to by neglect was the only conclusion that could be reached on the evidence.
“Olly was born a healthy baby boy and Emma and Michael were full
of joy and excitement about the future the family had to look forward to.
“However all of that was taken away from them when the safety guidelines that exist to prevent this type of incident from occurring were not adhered to.
“All we can hope is that the action plan put in place by the Trust ensures that no other families have to go through what Emma and
Michael have.”
The Trust has pledged to do all it can to avoid any future tragedies.
Chief nursing officer Tyrone Roberts told The Bolton News: “Our thoughts and sympathies remain with Olly’s family following the tragic loss of their son.
“Since Olly’s death, we have implemented a number of changes to minimise the risk of such a tragedy happening again.
“We fully accept that the care we gave Olly and his family was not acceptable.
“Whilst nothing we say can take Olly’s family’s pain away, by continuing to do everything we have outlined, our expectation is that no family will have to experience this in future.
“We are incredibly sorry that these mistakes were made.”