Loss of trust on Jersey General Hospital labour ward before birth - inquest

The inquest into the death of Amelia Clyde-Smith opened at International House on Monday

A midwife has told an inquest of a breakdown in trust on the labour ward ahead of the birth of a child in difficult circumstances.

Ewelina Clyde-Smith gave birth to Amelia Clyde-Smith on 19 August 2018 in Jersey General Hospital. Amelia died aged 33 days.

An inquest into her death heard how a labour ward co-ordinator left the hospital the night before her birth.

The inquest heard this was "unusual" and had a "huge impact" on staff.

The hearing was told the co-ordinator leaving the ward the night before Amelia was born was "common knowledge" among maternity staff.

However, coroner Bridget Dolan KC said it was "not documented anywhere" for five years after her death.

Ms Dolan said it was "not in the police investigation, not in external reviews… not in the viscount's investigation".

In a letter, the parents of baby Amelia said they felt no-one in the hospital had her interests in mind on the night she was born, the inquest heard

Midwife Lee-Ann Davies-Storer told the inquest the labour ward co-ordinator left the hospital the night before Amelia's birth to attend the home birth of a mother she knew.

This left a midwife who was not a co-ordinator in charge on an "extremely busy with several high risk patients", she said.

Ms Davies-Storer said this was "unusual" and had a "huge impact" on staff, "because we'd lost trust in her".

The labour ward co-ordinator was present the following night when Amelia was born.

Subsequently, Ms Davies-Storer was told not to include the absence in her serious incident statement, the inquest heard.

She told the inquest: "I was going to include [it] and I was told it wasn't factual and relevant to the case, so I was told not to include it.

"I've felt guilty for not including it."

'Form of censorship'

Tambu Muoni was the midwife attending Mrs Clyde-Smith on the night of Amelia's delivery. She told the inquest all the midwives were "very shocked" when the labour ward co-ordinator left the night before.

Ms Muoni also said she felt there was a "form of censorship" about the whole event. She said a different labour ward coordinator had asked her to remove details of it from her serious incident statement.

The labour ward co-ordinator told the inquest she was "aware that it was an unusual situation" for her to leave the ward.

However, she said the feelings of her colleagues "came as real shock".

The midwife co-ordinating the labour ward left the hospital the night before Amelia was born to help with the home birth of someone she knew, the inquest heard

On Monday, Mrs Clyde-Smith told the inquest about her birthing experience.

She said she was "wandering on the labour ward trying to find someone" to give her pain relief.

She added the "state Amelia came out in… was horrible to watch" and she was aware of "things going wrong" with a resuscitation machine.

The coroner read out a letter Mr and Mrs Clyde-Smith sent to the Deputy Viscount asking for Amelia's death to be investigated.

In it, the parents raised a number of concerns including the absence of doctors, the long wait for an epidural and staff failing to monitor the baby's distress before birth.

"We felt like no-one had Amelia's interests in mind that night," they wrote.

The coroner said the inquest was due to conclude on Friday.

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