Derriford Hospital 'missed chances to save baby's life'

Giles Cooper-Hall, pictured in the first few hours of his short life

A hospital missed several opportunities to save a baby who died 16 hours after he was born, a report has found.

Giles Cooper-Hall died from a brain injury caused by lack of oxygen at Derriford Hospital in October 2021.

"Ineffective communication during multiple handovers" was a factor in the baby's death, the Healthcare Safety Investigation Branch report found.

The University Plymouth Hospitals NHS Trust said all safety recommendations from the HSIB would be implemented.

The trust expressed its "sincere condolences" to Giles's parents Ruth Cooper-Hall and her wife Allison.

In a statement, it added: "The pain and distress they have experienced is immeasurable and our thoughts are with them."

'Source of distraction'

The hospital referred the case to the HSIB, which is tasked with independently investigating safety incidents "without attributing blame or liability".

The HSIB report said Giles Cooper-Hall died from a brain injury caused by an interrupted supply of oxygen to the brain on 28 October 2021.

It also highlighted that a doctor's advice to continuously monitor the baby's heartbeat was not passed on to the relevant staff.

It said it was likely "multiple tasks" being undertaken by the clinician was a "source of distraction" and contributed to staff not being "fully informed".

The report revealed the baby's heart rate was checked intermittently instead, and a handover from day to night staff resulted in failure to check Ms Cooper-Hall's written records.

In addition, the HSIB said an emergency was not declared following difficulty locating and monitoring the baby's heart rate.

The report also touched on mum Ruth Cooper-Hall's concerns that her baby was not moving as much as normal when she was 41 weeks pregnant, also known as reduced foetal movements.

However she was discharged and she later described the team as "really positive" and "not concerned at all."

'Grieve forever'

The Cooper-Halls said there were "failures in care, missed opportunities and delay in recognition of the severity and urgency of the situation".

Ruth Cooper-Hall said: "Our utter sadness and despair at losing Giles has been joined by anger and hurt as we now know that human error contributed to his death.

"We should have come home with our baby - we will grieve for him forever."

She added: "We had concerns at the time with the care we received in the delivery suite, including the inexperience of staff, the lack of communication, the lack of confidence and the environment of fluster and panic but we left Derriford having been given the impression that what happened to Giles was just a tragic accident.

"We thought it had all happened in the last 10 minutes of labour but the report reveals such a larger timeframe of errors, missed opportunities and delay."

Ruth and Allison Cooper-Hall said they would grieve for their baby forever

The report made five safety recommendations to Derriford Hospital following the incident.

These included staff completing a risk assessment at every point of care, as well as complying with local and national guidance.

It also highlighted that staff should recognise that when a baby's heart rate is slow or cannot be heard, an emergency should be declared.

A spokesperson for University Hospitals Plymouth NHS Trust said: "May we reiterate our most sincere condolences to the family on the sad loss of their son, Giles.

"The pain and distress they have experienced is immeasurable and our thoughts are with them.

"We would like to reassure people that all the safety recommendations stemming from the investigation will be fully implemented as part of our commitment to foster a culture of learning, development and improvement within the maternity setting."