Coroner finds 'gross' failings by Chelsea & Westminster hospital behind baby Elton's death
Senior coroner Professor Fiona Wilcox concluded that clients Eli Hoy and Tijl Deutekom's first baby died from natural causes contributed to by neglect by hospital staff at the Chelsea and Westminster hospital in January 2022.
The inquest heard that Elton's mother Eli was in excruciating pain following an abrupted placenta that was not picked up by the care team. The midwife in the room also failed to notice serious decelerations in Elton's heart rate clearly shown by CTG monitors.
Elton was starved of oxygen and pronounced dead 37 minutes after his birth. The coroner included in her summary concerns that the midwife caring for Eli wrote her medical notes 4-5 hours after the events, with the assistance of a supporting midwife.
'She threw away the contemporaneous record. It appears to me to be improper for a person who may be implicated in a death to be assisted writing up their record,' Prof Wilcox said.
Prof Wilcox also raised initial concerns that the hospital had tried to cover-up the death by not referring it to the coroner and wrongly informing HSIB that Elton had been stillborn and no investigation was needed. Neonatal death was the actual record which would automatically mean the coroner would investigate.
It was not until Elton's parents learnt of this anomaly in the records that an investigation was carried out by the HSIB, which uncovered serious failings in his care.
After hearing further evidence from the hospital trust, the coroner concluded that senior clinicians at the hospital did not understand the regulations for referring a baby's death for inquest.
Helen Thompson, representing Elton's parents, told ITV News that this begged the question whether other baby deaths have also been wrongly reported.
Elton's mother said to the Times which also reported the inquest:
'Knowing that Elton's death could have been avoided is both validating and deeply tragic. We believed that we were in a safe place, with the people and the technology surrounding us to help us.
'Maternity staff did not listen to our repeated concerns. They did not provide the basic level of monitoring. They did not act in our family's best interest. And they did not take accountability for it until now - nearly three years later. Surely, the medical community can do better.
'We are left to live a life without our first born. A life of all of the could-have-beens and should-have-beens. Our second son, Beau, will never get the chance to know Elton nor have the chance to play, to laugh, to cry and to bond with his brother.
'Please do better - please listen and trust women in distress, please act wisely and swiftly when they are in danger, and please take accountability for your mistakes so that others don't have to suffer through the same fight for justice.'
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