Newborn baby may have survived if consultant had not left room during difficult birth at hospital where there have been at least 20 maternity deaths, coroner says

A coroner has said that a newborn baby may have survived if a consultant had not left the room and the child had been born a few minutes earlier.

The hospital - which has been linked to 20 maternity deaths or serious harm cases - accepted there were failings in their care and offered their sincere condolences for the 'devastating loss' of the baby.

Freddie Barnett's delivery at the hospital in Barnstaple, North Devon, in June 2017 was difficult because of his low heart rate and poor condition.

Despite the best efforts of midwives, Freddie died 30 minutes after his birth.

Today his mother Charlotte Barnett, 30, gave an inquest a harrowing account of Freddie dying minutes after he was delivered. 

Freddie Barnett's delivery at the hospital in Barnstaple, North Devon, in June 2017 was difficult because of his low heart rate and poor condition

Coroner Nick Brown said Freddie might have survived if the consultant had not left the room and the baby had been one or two minutes sooner.

Mrs Barnett told the four-day inquest in Exeter, Devon, that her son Freddie was breached and his foot was delivered as midwives were told by a doctor to push on her stomach in an effort to deliver the baby naturally.

She said in a statement to the coroner that the midwives panicked and pressed the emergency button.

She said a doctor in scrubs rushed into her room at the North Devon District Hospital and examined her and thought Freddie was breached, despite earlier assurances that he was no longer breached.

She said a second doctor came into the room and one said 'is the theatre free' to which the reply was 'yes'.

Mrs Barnett said the doctor said there were two options - a natural birth or an emergency Caesarian section.

She said before she could answer midwives put her legs in stirrups.

Mrs Barnett said: 'He (the doctor) did not tell me about the risks. If the risks had been explained I would have had C section...even if it had risked my life.'

She said she was in excruciating pain as the harrowing ordeal continued as baby Freddie's head was stuck and she claimed the doctor shouted at the midwives to 'push my stomach'.

Freddie was delivered immediately and taken to a trolley and Mrs Barnett did not see him.

A paediatric nurse returned to the room to say they had done everything they could to save Freddie, and Mrs Barnett screamed at them to 'keep trying'.

A nurse then told her Freddie had died and he was brought over for Mrs Barnett to hold him and she said she was 'absolutely inconsolable'.

She claimed the doctor put his hand on her arm and said: 'I know how you feel, my wife had a stillborn. I was heartbroken. Freddie was not stillborn.

'He did not even say he was sorry for what had happened.' 

The hospital trust - where around 20 maternity deaths of serious harm cases have been linked - accepted there were failings in their care and offered their sincere condolences for the 'devastating loss' of the baby

Mrs Barnett, now 33, said afterwards: 'I am angry at what happened. It's just time unfortunately, if he had been delivered quicker, who knows.' 

Mrs Barnett, of Westward Ho! Devon, had given birth to her first two children naturally without any problems.

Her mother, Daphne Bickell, was with her at the time of the Freddie's death in June 2017.

She told the inquest at Exeter's County Hall said the midwives 'panicked' when Freddie's foot emerged.

She said as medical staff tried to deliver Freddie the scene looked 'barbaric'.

A 2017 review at the hospital raised 'serious questions' about maternity care at the Barnstaple based hospital.

An investigation by the Royal College of Obstetricians and Gynaecologists in 2017 expressed concerns with the 'decision making and clinical competency' of senior doctors and their co-operation with midwives.

An independent review into midwifery in October 2017 noted 'poor communication' between medical staff on the ward for more than a decade.

The report identified a 'lack of trust and respect' between staff and anxiety among senior midwives at the quality of care. 

Today the Northern Devon Healthcare NHS Trust Chief Executive Suzanne Tracey said: 'The loss of a baby is devastating and we want to express our condolences to the family for the loss of Freddie.

'Whilst nothing can ever make up for the family's loss it was really important to the Trust to learn from what happened.

'When this happened in 2017 the Trust immediately accepted there were failings in their care and this was one of the cases that prompted the Trust to take action.'

She said maternity services in the three years since have taken 'positive steps' forward and are confident services for mothers and babies are stronger.