A mother from Lincolnshire lost her baby just two days after the birth, after she was not reviewed for gestational diabetes.
Catherine Byrnes, from Waddingto, Lincolnshire had been under the care of Lincoln County Hospital. Baby Robert Goddard had been born six days late and delivered by emergency caesarean section. He had stopped breathing and, whilst his breathing was restarted, Robert was left brain damaged from having been deprived of oxygen and died in his parent’s arms two days later.
Coroner Stuart Fisher noted a number of failings that had lead to the mother’s likely gestational diabetes not being spotted, despite having been at high risk. Miss Byrnes had not had her care led by a consultant, had missed out on having her weight taken or BMI calculated and, crucially, two urine samples that had shown high levels of glucose had not been acted upon.
An additional failing was that there had been a delay in the delivery of the baby. If gestational diabetes had been spotted, it would have been usual to bring forward the delivery between weeks 39 and 40.
Following the death, United Lincolnshire Hospitals Trust put in place an action plan to prevent reoccurrence of the problems. The Trust had been identified as one of 14 hospitals that had demonstrated higher death rates by the Keogh Mortality Review.
In conclusio, the coroner, Mr Fisher said: “It is crucial that the Trust continue with the action plan since put in place and reinforce the failings that occurred and adhere strictly to procedures applied to their work.”
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