Home news Baby Rafe Angelo died after series of delays, inquest finds

Baby Rafe Angelo died after series of delays, inquest finds


A series of delays, including an ambulance crew’s detour for a toilet break, played a major part in the death of a newborn baby, a coroner has said.Rafe Angelo died from oxygen starvation shortly after being delivered at the Queen Alexandra Hospital, Portsmouth, in September 2014.The inquest heard no doctors or midwives met the ambulance on arrival.In a narrative verdict, Coroner Karen Harrold said the delays were a “critical system failure”.At a previous hearing in 2016, Rafe’s mother Kelly told the inquest she had been “screaming with pain” during her labour at the midwife-led Blake Birthing Centre in Gosport.She felt “something was wrong” and repeatedly asked for a transfer to hospital.

The hearing was told a new midwife at the centre did not know how to make an emergency call and took several hours to grant the request.An ambulance crew, which had not been told the call was “time critical”, then made a 13-minute detour for a toilet break before collecting her.On arrival at hospital, she was taken to the wrong door and there were no midwives or doctors to meet her.Rafe was born shortly afterwards but died 37 minutes later.The inquest heard he would almost certainly have survived if Ms Angelo had given birth an hour earlier.

Resuming the hearing on Tuesday, the Portsmouth coroner said she would be writing to organisations involved.Outside the court, the family’s solicitor Victoria Hydon said hospital staff were not warned about the seriousness of Kelly’s condition which caused a further 20-minute delay.In a statement, Portsmouth Hospitals NHS Trust, which runs the hospital and the birthing centre, said it had made a “number of changes” following the death.South Central Ambulance Service said the toilet break was approved by ambulance controllers, after the crew had spent three hours at an earlier emergency.Director of operations Mark Ainsworth said: “Based on the information provided the call was categorised as requiring an emergency ambulance response within 30 minutes.”Midwifery staff were not familiar with the Time Critical Transfer Process for requesting an ambulance.”
Source: BBC Hamp