A health chief has apologised to the parents of a day-old baby who died after a series of mistakes and missed opportunities at a scandal-hit NHS hospital.
Alison Williams admitted that 30-weeks pregnant Jessica Webb should have been transferred to a specialist unit to give birth to her premature baby.
An inquest heard that little Nelly Webb was born by Caesarian section at the Royal Glamorgan Hospital in South Wales.
The hearing was told that the maternity services were put into special measures after a damning review revealed at least 60 stillbirths were not properly reported or investigated.
The 2lb 9oz infant, born on New Year’s Day 2019, died after one of her lungs collapsed and a drain was inserted, potentially injuring her.
Little Nelly Webb was born at just 30 weeks gestation and only weighed 2lbs 9oz but tragically died the next day
Jessica and her husband Rikki (pictured together) were told Nelly died because she was so premature. No post mortem examination was held and the cause of death was reported to the coroner as natural causes
Jessica and her husband Rikki were told Nelly died because she was so premature. No post mortem examination was held and the cause of death was reported to the coroner as natural causes.
But 18 months later the couple were shocked to receive a letter saying mistakes had been made and, the inquest heard, she would have been ‘rescuable’ with the right treatment.
Ms Williams, former chief executive of the Cwm Taf Morgannwg University Health Board, told the hearing: ‘It is heartbreaking for the family – I am sincerely and genuinely sorry for everything they have had to go through.’
South Wales Assistant Coroner Sarah Richards told Ms Williams it would have been ‘preferable’ for a high-risk pregnant woman to be admitted to the University Hospital of Wales in Cardiff, 12 miles away.
Ms Williams replied: ‘Looking at the information, I would agree with you.’
The tragedy happened at a time when staff at the Royal Glamorgan were not properly reporting baby deaths in the hospital’s neo-natal unit.
Ms Williams said at the time of Nelly’s death, on 2 January 2019, there was a serious shortage of midwives and a reliance on locum doctors, some of them still in training.
Ms Williams resigned in August 2019 following a damning report into maternity services at the Royal Glamorgan and its sister hospital, Prince Charles in Merthyr Tydfil.
Dr Nick Lyons, who carried out a review into Nelly’s death, also apologised to her parents after they were kept in the dark about the events leading up to her death.
He said: ‘I just feel for the family, I spent lengthy hours wrestling with whether we should inform them but it was the right thing to do. I would like to apologise to them for the stress that must have caused.’
Head of midwifery at the hospital, Kerri Eilertsen-Feeney told the inquest: ‘My concerns were around the lack of reporting – incidents were not investigated in a thorough and meaningful manner.
‘Morale was poor, staff were afraid of reporting because they would face judgement.
In a statement, Nelly’s parents said outside court: ‘Nelly was our first born and we were absolutely heartbroken when she died. We were told that she died from natural causes as a result of her prematurity’
‘I wasn’t involved in the day to day running of the unit, I was trying to resolve the governance issues and meet with the families that we had identified who had been subject of previous incidents.’
In written evidence, Jessica, 31, said she and her husband were taken to see their baby after being told her oxygen levels were low.
She said: ‘She was in her cot, we did not feel at that stage there was anything serious.
‘I was so happy to see my baby after a difficult pregnancy.’
But Nelly deteriorated suddenly and the couple watched as a team of doctors frantically tried to resuscitate her.
Jessica said: ‘We stood by as they administered drugs – it was horrific to watch. We felt so out of control, we couldn’t believe what we were seeing.
‘After a few moments a doctor took us to a side room, apologised and said Nelly was not going to make it.’
On January 2, the hospital started a serious incident report on Nelly’s death.
But Dr Iyad Al-Muzaffar, one of the consultants who tried to resuscitate the day-old baby and counselled her parents, said he was unaware of the report.
Dr Al-Muzaffar said Nelly had aggressive respiratory distress syndrome and a pneumothorax (a collapsed lung).
He said she died of a ‘rare complication’ and it was his view that the baby did not die from an injury caused by the chest drain.
More than a year after Nelly’s death, parents Jessica and Ricky were contacted by health chiefs at the Royal Glamorgan Hospital in South Wales to say mistakes had been made during her care
The consultant said: ‘We could have done things differently but it would not have made any difference to the outcome. Whenever I review a case there are always lessons to learn.’
The six-day inquest, in Pontypridd, is trying to discover if there were systematic failings at the Royal Glamorgan which, had one of the highest stillbirth rates in the UK.
In a statement, Nelly’s parents said outside court: ‘Nelly was our first born and we were absolutely heartbroken when she died. We were told that she died from natural causes as a result of her prematurity.
‘We really struggled after we lost Nelly, so much so that Jessica couldn’t return to her place of work.
‘We were shocked and devastated again just 18 months later when we received a letter from the health board completely out of the blue telling us that mistakes had been made.
‘We are still deeply traumatised by what happened, and the fact that we had been lied to for so long. The legal process has exposed what really happened to our little girl which has been even more upsetting.
‘We were so terrified of history repeating itself and having lost any trust at all in the care provided at the Royal Glamorgan Hospital, that we travelled to Cardiff to have our two boys in 2020 and 2023.’