Senior coroner accuses hospital of cover-up over baby's death

A senior coroner has accused Chelsea and Westminster Hospital of a cover-up after the death of a baby when midwives failed to act on clear signs that his mother was in distress.

Elton Deutekom was pronounced dead 37 minutes after his birth in January 2022. During labour his mother had a placental abruption, when some or all of the placenta separates from the wall of the womb. This was not picked up by her care team, and the baby was starved of oxygen. 

An inquest into the baby’s death was told that doctors at the west London hospital did not refer the incident to the coroner and wrongly told the NHS’s healthcare safety investigation branch (HSIB) that Elton Deutekom had been stillborn and that no investigation was required.

The HSIB carried out an investigation which uncovered serious failings in Elton Deutekom’s care after his parents learnt of this anomaly in the records.

Inner West London senior coroner, Professor Fiona Wilcox, said: “I need to say this on the record and in public — this feels like there has been an attempt at a cover-up.” She later repeated: “I am concerned there is an element of cover-up in this death. I will say it categorically.”

Concluding that Elton had died from natural causes contributed to by neglect, Professor Wilcox said there had been “gross” failings in his care. She added that if the midwives had adequately monitored his heart rate, acknowledged his mother’s pain and recognised hypoxia — oxygen deficiency — he would have been delivered earlier and would have survived. 

Professor Wilcox said she will issue a prevention of future death (PFD) report and raised a number of concerns about maternity care at the hospital. 

A home birth under the care of community midwives had been planned by Eli Hoy, 38, and her partner, Tijl Deutekom, 40, but because of a spike in her blood pressure when she went into labour, Eli Hoy was told to go to the maternity ward. 

Once there, she started vomiting and shaking and was in excruciating pain, but was assured that this was normal. As labour progressed, cardiotocography monitoring of the baby failed to detect his heart rate, but this was not reviewed or acted on by staff. Additional monitoring equipment that could have detected a problem was not used. 

Elton was eventually delivered by forceps and attempts to resuscitate him failed. A post-mortem examination concluded that the probable cause of his death was hypoxia. In Hoy’s medical records, Elton’s death was referred to as “neonatal”, a death occurring within the first 28 days, but the hospital reported it as a stillbirth, meaning that it did not require an investigation. 

Professor Wilcox said: “Evidence from the trust today suggests a fundamental misunderstanding at senior level of the regulations relating to which deaths should be referred to a coroner.”

In a statement, Hoy and Deutekom, said: “Knowing that Elton’s death could have been avoided is both validating and deeply tragic. We believed that we were in a safe place, with the people and the technology surrounding us to help us.

“Maternity staff did not listen to our repeated concerns. They did not provide the basic level of monitoring. They did not act in our family’s best interest. And they did not take accountability for it until now, nearly three years later. Surely the medical community can do better. 

“Please listen and trust women in distress, please act wisely and swiftly when they are in danger and please take accountability for your mistakes so that others don’t have to suffer through the same fight for justice.” 

Chelsea and Westminster Hospital NHS Foundation Trust said: “We are deeply sorry for the loss of baby Elton and offer our condolences to his family during this time. Our priority is always to provide the highest standard of care and we have taken learnings from this review to prevent a situation like this happening in future.”