Coroner rules death of baby at inadequate Royal Derby Hospital contributed to by neglect

12 March 2024

A coroner has today ruled that the death of a baby boy at the ‘inadequate’ rated Royal Derby Hospital was contributed to by neglect.

Coroner Susan Evans said at an inquest into the death of Zachary Taylor-Smith (Zac), which concluded today at Chesterfield Coroner’s Court, that there had been “total and complete failures in relation to basic care”.

Three weeks before the inquest was due to start, the hospital trust admitted that had anti-biotics been given to Zac’s mother, Hannah Taylor-Smith, and had earlier treatment for the Group Strep B infection that Zac contracted during his birth been given to him, Zac’s death could have been prevented. The admission was made as part of the medical negligence case that had been brought against it by Zac’s parents Hannah and Tim and their legal team.

Hannah and Zac’s father Tim Taylor-Smith said words alone were not enough to describe the pain of his avoidable death.

“Zac was perfect in every way; we fell in love with him the moment we laid eyes on him. We were so excited for our other children to meet him, to bring him home knowing that we had the final piece of our puzzle, and he was so loved by all. Nothing could have prepared us for what we were to witness, there is no pain like watching your child pass away and being totally helpless to stop it, with the added reality of breaking each of your children’s hearts as they come to understand their sibling is dead. We all struggle to navigate this new life without our child/baby brother, we all miss him so much it physically hurts.

“Zac was not a learning opportunity, nor should he have been a sacrifice made for the greater good. He was a child who was failed by the very people who should have protected, cared for and treated him.

“What is particularly hard to come to terms with is the catalogue of errors made in my and Zac’s care. Not one individual recognised that antibiotics should have been given to me during my labour, one simple action that the trust agreed would have made a difference. Midwives also did not recognise that he was deteriorating, which has been accepted was fundamental to their job.

“The hospital staff have referred to ‘individual human error’ but what we heard highlights wider systemic issues. To bring true change the trust needs to take overall responsibility for what happened to Zac, rather than lay the blame on individuals, and make drastic changes to the way it operates its maternity and neonatal services.

“From speaking to other bereaved families, we know that this is not just happening in one trust or in ‘dark corners’ of the NHS. It is widespread and babies are dying unnecessarily. Given that, we are joining the nationwide campaign in calling for a national inquiry into maternity services to shine the light on the truth”

Nicola Wainwright, a partner at JMW Solicitors London office specialising in maternity failures, is representing the family. She said: “Hannah and Tim have been through the worst pain imaginable, but they have continued to fight for answers, not just for themselves, but for every other family that has been affected by substandard maternity care at the Royal Derby Hospital.

“The evidence we heard suggests that once Hannah was in hospital for Zac’s delivery, there were negligent failings by nearly every single member of staff who saw her or Zac prior to his collapse.

“Errors were made which were described in evidence as ‘basic’ and ‘obvious’ - important factors that affected the assessment of Zac’s risk of infection were not noted, records were misplaced, a doctor forgot to review and handover Zac, obvious signs of an unwell baby were missed, charts were not completed, and the pathway designed to ensure ill babies are escalated was not followed – not once but repeatedly.

“I cannot imagine how hard it was for Zac’s parents to listen to failure after failure being listed especially when most of them could have been avoided if only a proper system had been in place and national guidance had been followed.”

The issues with the Royal Derby Hospital’s maternity services go back some time. In November 2023, the Care Quality Commission downgraded its rating to ‘inadequate’

Meanwhile prior to Zac’s birth on 17th November 2022, the Healthcare Safety Investigation Branch (HSIB) had carried out an investigation into maternal deaths and injuries at the trust as far back as 2021/2022. That report, published in February 2023, also identified concerns, including midwifery staffing levels, but it seems that lessons were not learned.

Zac was born on 17th November 2022 at 36 weeks, after Hannah was induced early due to recurrent asthma attacks. He was originally in a good condition but shortly after his birth showed signs of being unwell, including a low temperature, grunting and poor feeding. Despite this, Zac was not observed properly and not escalated when he should have been to the neonatal team. When the neonatal team was called, they did not attend, until a crash call was made when Zac collapsed some hours later. It also transpired that Hannah was not given antibiotics during labour, as she ought to have been, due to Zac’s prematurity and his post mortem revealed that he was infected by Group Step B bacteria. When Zac collapsed, there was a delay in summoning specialist neonatal doctors, which hindered his resuscitation.

JMW’s record of the inquest ruling, the hospital internal investigation and HSIB reports available on request.