A tiny baby died after “excessive force” was used during a botched forceps’ delivery - a coroner has revealed.
Little Frederick Terry - also known as Freddie - was eventually delivered by C-section but could not be saved.
Medics battled for 40 minutes to resuscitate him but nothing could be done.
The hospital involved was not named in the report but is understood to be Broomfield Hospital, which is part of the Mid and South Essex Hospitals Trust.
Essex Live reported an inquest into the tragedy was heard in September this year where it was recorded he was stillborn and no further evidence would be called.
However, Senior Coroner Caroline Beasley-Murray has prepared a report to prevent future deaths which she has sent to the trust.
In the damning document, she says: “Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on November 16, 2019, and death was confirmed after 40 minutes of resuscitation attempts.
“The cause of death at post mortem examination has been given as: 1a, hypovolaemic shock 1b, skull fracture and scalp laceration and haemorrhage 1c, birth trauma.
“The evidence showed that baby Freddie’s very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby."
In the report, Mrs Beasley-Murray said: “In my opinion, urgent action should be taken to prevent future deaths.”
Mrs Beasley-Murray found 11 matters of concern in her investigation, including:
• A lack of risk assessment leading up to the mother's delivery
• The forceps delivery was attempted without recognising an occipito-posterior position. The coroner said more training was required and use of scans developed
• The injuries imply an excessive degree of force in the application of the forceps and the traction
• Concerns about the engagement and induction of locum staff and management of staff levels on the maternity ward
• The need for a bleep in the neonatal unit
• Accuracy of record-keeping
• Training and procedures in respect of how communications should occur between all clinical personnel in the delivery theatre
• Training and procedures in respect of how communications with the family should be carried out
• Availability and suitability of resuscitation equipment and procedures on the maternity ward
• The trust’s Action Plan must be rigorously carried out
Under the eleventh point, Mrs Beasley-Murray said: “It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery.
“Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth.
“In March 2019, HM Government issued a consultation on coronial investigations of stillbirths.
“It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions."
The hospital in which Freddie died has not been named in the report.
The Mid and South Essex Hospitals Trust has been contacted for comment.
