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Baby Jasper Brooks died due to 'neglect' at hospital, coroner rules


Neglect contributed to a baby's death at the hospital where he was born, a coroner has ruled.

The coroner found gross failures by midwives and consultants at Darent Valley Hospital, Kent, where Jasper Brooks was born on 15 April 2021 and said the child’s death was "wholly avoidable."

Jasper was a second child for Jim and Phoebe Brooks whose first child, Oscar, was also born at Darent Valley Hospital.

On that occasion, the family had received good, prompt care after Phoebe Brooks had suffered a placental abruption, a condition when the placenta starts to detach from the inside of the womb wall.

Because of this, Ms Brooks was booked in to have an elective Caesarean section to deliver Jasper those plans changed overnight in April 2021 after a check-up found she had raised blood pressure.

She was told to remain in hospital and that the C-section would be carried out the following morning, nine days earlier than planned, when more staff were on duty.

Jasper's parents say the midwives repeatedly failed to listen to their concerns that Phoebe Brooks she was shaking violently, feeling sick, and thought she was bleeding internally.

Phoebe says: "We felt like an inconvenience. No one wanted to deal with me that night. The doctor didn't want to do my C-section; the midwife who’s meant to be looking after me, just doesn't really care.

"I remember saying clearly to her, 'my whole body is shaking, something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'."

Phoebe went into labour naturally, before the C-section could take place.

At the inquest, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary."

Ms Davis told the inquest that she had been traumatised by the case. She said:  "I thought, on the night, I was giving the best care I could. Everything I did that night wasn't done with any intent to harm."

Prior to baby Jasper's birth, staff struggled to find the unborn baby's heartbeat and did not spot that Phoebe was about to deliver.

Phoebe Brooks adds: "His whole body was born at once. I looked down and he was just so white. And then all of a sudden it was like, panic. One of the midwives picked up the baby and started rubbing him and was like, 'come on baby, come on baby'. "Then I thought, 'he's going to cry, he's going to cry. Why is baby not crying?'"

Jasper was born without a heartbeat, so a resuscitation team was called but the inquest heard that further errors were made because the correct people failed to attend the resuscitation.

There was no consultant neonatologist on site, a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe, which should only take a few minutes, did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart.

Twenty-seven minutes after Jasper was born, and still with no sign of a heartbeat, a consultant told his parents that were going to stop working on their son.

Phoebe says: "We were just in complete shock, 'how has this happened?'. I reached out and touched him, and basically his heartbeat came in, and then, all of a sudden, they were like, 'we've got a heartbeat'. They went from calling time and ending resuscitation to he's got a normal heartbeat."

The newborn was taken away for tests, but shortly afterwards a doctor returned and told the family further treatment would be futile because Jasper was very ill.

The family asked if he could be moved to another hospital for more specialised care, a possibility which had already been mentioned, but were now told there would be no point.

The family later learned that national guidelines state a decision to end care should be made by a multidisciplinary team comprising at least two consultants, not just a single doctor.

Mrs Books said "We did not agree with the plan they made. We asked if there's any other options, and we were told, 'no. You're going to go into monkey room [bereavement suite] and Jasper's going to die.'

"I remember holding him, uncontrollably crying, and just trying to treasure that moment with our son while we're waiting for him to die. But he kept taking another breath and another breath."

The longer Jasper lived, the more his parents were keen for further treatment be offered.  Rather than dying within minutes, as his parents had been told he would, Jasper died on 15 April 2021, having lived for 23 hours.

Phoebe Brooks added: “We wanted a lifetime with him, which was taken away from us because of how that hospital treated me in labour and how they treated him."

The Dartford and Gravesham NHS Trust says: "We are committed to learning from our mistakes to ensure no family has to go through this again. We are very sorry for the devastating impact this has had on the Brooks family. We have already taken significant action to improve our practices and will commit to implementing the additional recommendation from the inquest."