A MIDWIFE’S baby died after a series of “missed opportunities” which contributed to his death, a coroner concluded.
Little Dexter Bowker was born lifeless on 29 November, 2016 at North Manchester General Hospital.
Katie Bowker with husband Adam Bowker and son Harvey[/caption]
An inquest heard how staff had felt a pulse in his umbilical cord, which was looped loosely around his neck, but he could not be resuscitated.
His mum Katie Bowker, 39, is a midwife at Royal Oldham Hospital, also run by Pennine Acute NHS Hospitals Trust, and two colleagues had taken charge of Dexter’s delivery.
Her pregnancy was deemed “high risk” due to a foetal growth restriction, which was not spotted, and there were other mistakes by medics.
The mother-of-one, from Bury, Greater Manchester, told of the horrifying moment she learned Dexter had died after first being placed on her chest.
Fighting back tears, she said: “I held his (umbilical) cord and could feel his cord pulsations,” she said.
“But I remember thinking, ‘I haven’t heard him cry.’ I didn’t realise how bad it was until Nic (Nicola Jagat Singh) took him off me.
“Jenny (Brown) pulled the emergency bell and then everyone came in.”
She added: “I was thinking ‘he’ll come round in a minute. he will cry in a minute.”
Mrs Bowker’s friend and colleague Jenny Brown was her midwife[/caption]
Mrs Bowker’s friend and colleague Jenny Brown was her midwife for much of the time she was in labour.
She had delivered Mrs Brown’s first child Harvey but at the time was based on the hospital’s post-natal ward and had not worked on the labour ward for 18 months.
The inquest heard her training compliance was at 44 per cent and she’d requested “refresher” courses so her skills, including neonatal resuscitation, were up-to-date.
When asked if she felt confident looking after Mrs Bowker, Mrs Brown said: “I wouldn’t have done it otherwise.”
However, the inquest heard when Dexter was delivered he was “pale and floppy and there was no attempt to take breath.”
Pulsations were felt in his umbilical cord but they were not “adequate” and the alarm was raised.
Attempts were made to resuscitate Dexter but he was pronounced dead 50 minutes later.
Independent expert Dr Adam Gormall, a consultant in fetomaternal medicine for Shrewsbury and Telford Hospital NHS Trust, identified a number of concerns with Dexter’s case.
They included a “significant fall” in his growth rate towards the end of pregnancy which warranted “further investigation”.
A further ultrasound scan after 38 weeks gestation could have revealed the growth restriction and then Mrs Bowker would gave been offered an induced birth, he said.
He added that the “most likely” cause of Dexter’s death was hypoxia caused by a umbilical cord obstruction.
Recording Dexter’s death as natural causes contributed to by neglect, coroner Angharad Davis said: “Dexter’s delivery was high risk due to the fact that he had foetal growth restriction from 34 weeks gestation.
“There are several missed opportunities by the Trust to recognise this risk and act upon it.”
She added that the fact the growth restriction was not picked up meant he was not continually monitored during labour which “more than or trivially contributed to his death”.
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Speaking after the inquest Dexter’s parents Mrs Bowker and her husband Adam, 34, said: “Dexter was a very loved and beautiful little boy.
“We were all really looking forward to bringing him home and welcoming him to our family, none more so than his big brother, Harvey.
“He was only five-years-old when we lost Dexter and for him to deal with all this at such a young age is absolutely heartbreaking.
2This has devastated our whole family and it has been a complete nightmare for us all.”
Adam Bowker arrives for his son’s inquest at Manchester Coroner’s Court[/caption]