A NEWBORN baby died after ambulance staff used the wrong technique during delivery because they were unaware of the latest breech guidelines.
Jack Robinson-Morris died on April 18 from a severe brain injury – aged just three days.
His parents Sarah Robinson, 30, and James Morris, 37, are now calling for lessons to be learned following their son’s tragic death.
Sarah was 33 weeks pregnant when she started to develop serious pains and suffered blood loss on April 15 this year.
Her husband called an ambulance at 6.14am – which arrived 27 minutes later.
An ambulance that was closer to the family home in Solihull, in the West Midlands, wasn’t sent because the crew were about to finish their shift.
This meant there was a 12-14 minute delay. The controller felt it would be better to have fresh crew attending, rather than staff at the end of their shift.
By 7.08am Jack’s legs, body and left arm were delivered spontaneously in the back of the ambulance.
Paramedics pulled over and unsuccessfully tried to deliver his head before continuing with their journey to hospital.
At hospital he was taken to the neonatal unit where he was found to have suffered a severe brain injury caused by a lack of oxygen when his head was trapped during delivery.
He died three days later.
A subsequent internal investigation by the West Midlands Ambulance Service NHS Foundation Trust [WMAS] found staff who tried to deliver Jack used the wrong technique.
They had not seen the latest guidelines on how to deal with such an incident and the last mandatory maternal emergencies training was five years ago.
Mum Sarah said: “It remains incredibly hard to think about what happened to Jack and it is still hard to believe that he is gone.
“Every day is a real struggle. Our arms ache to hold our little boy again. Jack was the most perfect and beautiful little boy who we miss so much.
“It is so difficult not to be angry about what happened, how we feel let down and most importantly how we feel Jack was let down.
“I should be holding my boy in my arms, instead Jack passed away peacefully on my chest. I wouldn’t wish the pain our family is going through on anyone.
“All we can hope for now is that he didn’t die in vain and the ambulance services learns from what happened to him so others don’t have to live with the pain our family is having to endure.”
The WMAS report made seven recommendations including all staff undergo training, guidance cards of what to do during complicated pregnancies be introduced and all control staff be reminded of the service’s end of shift policy.
An inquest held in August identified a range of concerns, including the ‘wrong’ ambulance being despatched which delayed Jack’s arrival in hospital.
The couple are now calling for WMAS to implement the recommendations to prevent similar incidents happening again.
Zoe Smith, expert medical negligence lawyer at Irwin Mitchell, who are representing the family, said: “This is a truly heart-breaking case with Jack’s death understandably having a huge impact on the family.
“Many months after Jack’s death Sarah and James are still struggling to come to terms with the events that unfolded.
“The findings included in the Ambulance Trust’s own report and the findings of an inquest into Jack’s death are worrying.
“We recognise that the Ambulance Service has made several recommendations in its incident report and we urge it to ensure these are implemented as soon as possible to improve patient care for others.”