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Baby lived for only 14 hours after failings in care.


A baby boy who lived for only 14 hours died from Group B Strep after "total and complete failures" in his care, an inquest has ruled.

Zachary Taylor-Smith developed breathing problems and died in November 2022 after what his parents called "appalling treatment" at the Royal Derby Hospital.

Chesterfield Coroner's Court was told Zachary, the couples’ fifth child, was born at 36 weeks after his mother Hannah was induced because of recurrent asthma attacks. 

The inquest heard he was initially healthy, but soon became unwell, suffering a low temperature and poor feeding, and that neglect had contributed to his death.

Midwives previously told the inquest that “incorrect" actions were taken and it was an error that Zachary was not reviewed by the neo-natal team.

University Hospitals of Derby and Burton NHS Foundation Trust (UHDB), which runs the hospital, admitted that had antibiotics been given to Hannah before his birth, or if Zachary had been treated for infection after birth, his death from Group B Strep could have been prevented. 

East Midlands assistant coroner, Susan Evans, said there were multiple "missed opportunities" to refer Zachary to a neo-natal team during his short life that, on the balance of probabilities, would have prevented his death.

She confirmed she would be writing a prevention of future deaths report about Zachary's death.

The inquest heard the referrals to the neo natal team did not happen, despite warning signs such as a raised respiratory rate and poor feeding.

Susan Evans said there were "total and complete failures" relating to the provision of basic care, and "gross failings" relating to the fundamental requirements of patient care.

In a statement after the hearing, Tim and Hannah Taylor Smith, from Lichfield, Staffordshire, said: "Zac should have been reviewed by a neonatal doctor at birth and urgently on at least five occasions before he was finally seen when we pressed the crash bell ourselves. By then it was too late to save him."

Tim and Hannah added: “We think that there needs to be a full review of this country's maternity services. This is not just happening in one trust or in 'dark corners' of the NHS."

The Taylor-Smiths have called for Donna Ockenden, who is leading the biggest ever investigation into NHS maternity failings in Nottingham, to expand her review to Derby and Burton-upon-Trent.

The trust's maternity services were rated inadequate by health and care regulator, the Care Quality Commission in November 2023. 

The hospital trust said that since Zachary's death, changes have been implemented to improve services, including a new scoring tool to "quickly and consistently identify any deterioration in newborn babies" and a toolkit, which supports maternity units to build a culture that enables effective clinical escalation. 

Executive chief nurse at the trust, Garry Marsh, said: "The loss of a baby is devastating, and we are sincerely and deeply sorry for the failings in Zachary's care, which we fully accept. We should have provided antibiotics and responded differently to changes in Zachary's condition and we have been determined to put changes in place."