Day-old girl died after 'systemic failures' at scandal-hit maternity ward where staff didn't have the 'skill or experience' to deliver a premature baby and 'probably' would have survived if her mother had been moved to a better-equipped unit, inquest told
A day-old girl died after 'systemic failures' at a scandal-hit NHS hospital where staff didn't have the 'skill or experience' to deliver a premature baby, an inquest has found.
Nelly Webb would 'probably' have survived had her 30-weeks pregnant mother been transferred to a unit equipped to deal with her complex needs, the coroner concluded.
But she died after mistakes and missed opportunities at the Royal Glamorgan Hospital, later put into special measures with 70 recommendations made.
Doctors told parents Jessica and Rikki Webb that Nelly died because she was so premature but, 20 months later, the couple were 'shocked' to discover they had been 'lied' to and a catalogue of mistakes covered up.
The six-day inquest heard the infant had respiratory distress syndrome, a collapsed lung and weighed only 2lb 8oz - but was 'rescuable' with the right treatment.
Little Nelly Webb was born at just 30 weeks gestation and only weighed 2lbs 9oz but tragically died the next day
Jessica and her husband Rikki (pictured together) were told Nelly died because she was so premature. But a coroner said Nelly would 'probably' have survived had her 30-weeks pregnant mother been transferred to a unit equipped to deal with her complex needs
Health chiefs have since apologised over the death of the newborn at the troubled NHS maternity ward of Royal Glamorgan Hospital (pictured)
South Wales Assistant Coroner Dr Sarah Jane Richards recorded a narrative verdict that Nelly 'would have likely survived' had Mrs Webb been transferred to give birth at a neo-natal intensive care unit.
She said: 'The statement of the baby's mother made damning reading of a service in disarray. There was insufficient attention to tests, medication and treatment from a team which appeared fragmented with multiple doctors and nurses providing different care plans.
'She was not considered for transfer. Instead, the plan appeared to be to keep the baby in utero for as long as possible and then deliver at the Royal Glamorgan Hospital.
'There was no discussions between obstetrics and neonatology about the imminent birth and the likely need for intubation, ventilation and specialist care.'
Dr Richards said the on-call consultant should have been called in, while supervision of junior doctors was inadequate and follow-up care the next day was 'poor'.
The coroner said a consultant failed to spot Nelly had a pneumothorax (collapsed lung) and called a delay in inserting a chest drain a 'missed opportunity'.
When the drain was inserted it went into the wrong place.
Dr Richards added: 'There was an overall lack of competence'.
The coroner ruled the hospital was guilty of 'systemic failures' under the Right to Life section of human rights law - and said doctors who investigated Nelly's death found it was 'probably avoidable'
The coroner ruled the hospital was guilty of 'systemic failures' under the Right to Life section of human rights law (pictured are Nelly's parents)
But Dr Richards recommended no further improvements for the hospital after hearing 70 recommendations had already been made following inspections by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives.
Alison Williams, former Chief Executive of Cwm Taf Morgannwg Health Board, which runs the hospital, apologised to Nelly's parents.
Ms Williams said: 'It is heartbreaking for the family - I am sincerely and genuinely sorry for everything they have had to go through.'
She agreed with a suggestion by the coroner that it would have been 'preferable' for a high-risk pregnant woman to be admitted to the University Hospital of Wales in Cardiff, 12 miles away.
The tragedy, on January 2, 2019, happened when staff at the Royal Glamorgan were not properly reporting baby deaths in the neo-natal unit, there was a serious shortage of midwives and reliance on locum doctors.
Ms Williams resigned in August 2019 following a highly-critical report into maternity services at the Royal Glamorgan, in Talbot Green, and its sister hospital, Prince Charles in Merthyr Tydfil.
Dr Nick Lyons, who carried out a review into Nelly's death, also apologised to her parents after they were kept in the dark about events leading up to her death.
He said: 'I would like to apologise to them for the stress that must have caused.'
In written evidence to the Pontypridd inquest, Mrs Webb, 31, said she and her husband were taken to see their baby after being told her oxygen levels were low.
Mrs Webb said: 'She was in her cot, we did not feel at that stage there was anything serious.
'I was so happy to see my baby after a difficult pregnancy.'
More than a year after Nelly's death, parents Jessica and Ricky were contacted by health chiefs at the Royal Glamorgan Hospital in South Wales to say mistakes had been made during her care
But Nelly deteriorated suddenly and the couple watched as a team of doctors frantically tried to resuscitate her in a 'horrific' scene before they were taken to a side room and told the infant was 'not going to make it'.
At the inquest, Nelly's cause of death was given as a pneumothorax, severe respiratory distress syndrome and prematurity.
Nelly's parents – so 'terrified' of the prospect of history repeating itself that they travelled to hospital in Cardiff to have their two sons in 2020 and last year - said outside court: 'We are still deeply traumatised by what happened, and the fact that we had been lied to for so long.
'The legal process has exposed what really happened to our little girl which has been even more upsetting.'
Diane Rostron, the couple's solicitor, added: 'Jessica and Rikki lost their first-born little girl in circumstances that could have been avoided.
'The family will now pursue a medical negligence claim against the hospital.'
Ms Rostron revealed the claim is one of 12 she is pursuing over incidents at the Royal Glamorgan and six for incidents at Prince Charles Hospital, run by the same health board including a catastrophic brain injury.
She is also pursuing 14 birth injury claims against other Welsh health boards.
Paul Mears, chief executive of Cwm Taf Morgannwg University Health Board, said: 'We fully accept the findings and extend our sincere apologies to Nelly's family.
'We are committed to learning from such tragic events to ensure that they do not happen again.'
