Inquest into the death of newborn at University Hospitals Sussex NHS FT
Following a two-day inquest in Horsham, Senior Coroner Penelope Schofield concluded that there was a missed opportunity to avoid the death of baby Jax Miller, who died at just one day old following a delayed diagnosis of volvulus, known to be a time critical medical emergency.
Jax was born in good condition on 7 June 2023 and was discharged home following a normal NIPE (newborn and infant physical exam), despite his mother raising concerns about his reluctance to feed
Jax was born in the early hours of the morning and was recorded to only have had one feed prior to discharge. His mother had also reported that he had vomited several times, which was not further investigated.
Following discharge, Jax remained reluctant to feed, continued to vomit and remained unsettled. His mother contacted the Princess Royal Hospital the same evening. Despite speaking to an Advanced Neonatal Nursing Practitioner (ANNP) and telling them of Jax's reluctance to feed and vomiting which was yellowish/greenish in colour and getting darker, a known red-flag for volvulus that should have been investigated urgently. Jax's mother was not advised to attend hospital immediately and was reassured that all was fine.
The following morning Jax's mother took him to the Royal Alexandra Children's Hospital By this time, Jax was in shock and doctors proceeded to a laparotomy for suspected volvulus. The surgeon found a 360° malrotation with completely dead small bowel and concluded that his condition was incompatible with life and he was redirected to a palliative pathway and passed away in the evening of 8 June 2023.
The coroner found that the ANNP who advised Jax's mother on the evening of 7 June, did not consider that Jax may have had a volvulus and was influenced by a normal NIPE assessment and comments by other midwives about Jax's feeding prior to discharge, and that the level of importance of getting Jax reviewed was not emphasised to his mother who was falsely reassured by the advice given.
The Coroner concluded that there was a missed opportunity to provide Jax with urgent medical care due to an omission in communicating to his mother the appropriate actions to be taken should his condition become acute. She found that this missed opportunity to provide urgent medical care and the provision of insufficient guidance to Jax's mother, deprived her of the opportunity to act when her son was well which contributed to his death.
Following conclusion, Jax's mother said: "Jax's death has been utterly devastating. I am haunted by his loss and the failures that led to this, I feel wholly let down by the Trust and the clinician's involved in Jax's care. Jax was very much longed for, he was my rainbow baby and he was truly perfect. The love I have for him will last a lifetime and I feel that I have been robbed of the time I would have had with him."
This verdict follows University Hospital Sussex NHS Foundation Trust being identified as one of the most concerning trusts being investigated under the government's national maternity and neonatal services review.
Nine bereaved families, who lost babies following failings in the Trust’s maternity care between 2021 and 2023, recently united to call for a public inquiry specifically into the service being delivered by University Hospitals Sussex.
Currently the maternity services at Princess Royal Hospital, one of the hospitals within the Trust, is rated as requires improvement.
A report carried out by CQC in December 2021 also found that the service did not manage safety incidents well. Staff did not have time to report incidents and near misses. Many only reported what they construed as the most serious incidents, and this was typically done only after their shifts had finished. They indicated that they had been instructed to stop reporting low staffing as an incident as it was a known risk. Some did not understand the duty of candour, a legal obligation to be open and transparent with patients when something had gone wrong.
Louise Astill represented the family at Inquest with Jo Moore at 1 Crown Office Row. Louise said:
"This terrible loss may have been preventable had Jax been afforded the right care. It is heart-wrenching that Jax's family and other families in similar circumstances have had to live through the trauma of losing a child and having to relive that trauma to get answers.
Jax's family is determined that no other family should have to go through what they have. They hope that learning will come from Jax's death and that the review into maternity and neonatal services at the Trust will ensure improvements in care and the safety of babies and their mothers."
Louise Astill is an Associate in Fieldfisher’s Medical Negligence team, working closely with individuals and families who’ve have experienced substandard medical care. Louise focuses on helping people navigate complex claims—from birth injuries and brain trauma to delayed cancer diagnoses and psychiatric harm—with empathy and clarity.
Her approach is client-focused and thorough, guiding clients through the legal process with empathy and determination, aiming to secure early support and the best possible outcomes.
Louise has successfully achieved multimillion-pound settlements, early admissions of liability, and has represented bereaved families during inquests and mediations, helping them gain answers and drive changes in medical practice.
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