A NEWBORN Haverfordwest baby died in hospital of shock brought about by a high loss of blood during birth, an inquest has concluded.

The inquest into Callum Ragan James’ death ran into a second day at County Hall.

Senior Coroner for Pembrokeshire Paul Bennett confirmed Callum was born at 11.08pm and at 11.34pm efforts to resuscitate him were abandoned after steps were taken to get his lungs working and circulation started.

"I cannot imagine how distressed Mr and Mrs James felt when their son did not survive," said Mr Bennett.

"This has been a very difficult inquest to hear. I would like to pay tribute to Mr and Mrs James in their fortitude of this case.”

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The inquest heard how, on May 5, 2016, Ellie James, of Haverfordwest, went to Withybush Hospital where it was confirmed she was in the early stages of labour.

She then went across to Glangwili Hospital where she was met by duty midwife Ebba Lewis.

From here Mrs James was taken to the midwifery-led unit and offered a pool to give birth; however things started to go wrong.

Mrs James was taken out the pool and transferred to a bed with attempts to take her upstairs to the labour-led ward, where consultants would be waiting.

However, Mrs James was too far along for the transfer to be made and gave birth to Callum in the midwifery ward at 11.08pm.

Attempts were made to resuscitate Callum, but at 11.34pm efforts were abandoned.

At the inquest, Mrs James questioned why she gave birth to Callum in the midwifery-led unit when, due to complications with her first pregnancy; she said she was assured she would give birth to Callum in a labour-led unit.

Mrs James also questioned whether her own concerns about unusual pains she experienced in the abdomen in the run-up to the birth could have played a part in Callum’s fate.

Mrs James said: “When Callum was born, I was ecstatic. To me he looked perfect. It was not until I saw the midwife’s face that I knew something was not right.”

When pressed by family counsel Jodie Kembery about the pains and whether Mrs Lewis was aware of them, the midwife replied: “We asked how she is feeling. I do not recall specifically asking about the abdominal pain.”

Ms Kembery then directed her line of questioning on whether Mrs James should have been admitted to the labour-led ward on arrival at Glangwili. Mrs Lewis explained that patients can only be admitted to the ward when deemed high risk.

Ms Kembery asked: “Given Mrs Ellis had consultant-led care throughout pregnancy would that qualify her for giving birth in the labour ward?”

Mrs Lewis replied: “No because she was not deemed as high risk [on arrival to Glangwili]. There were no signs of deviation from the normal, so she was classed as low risk.”

Along with Mrs Lewis, her colleague Linda Leeves, who was the senior midwife on the day of Callum’s birth, also gave evidence.

Ms Leeves was called by Mrs Lewis to provide assistance during the pregnancy.

Ms Leeves explained: “I entered, and Mrs James was on the bed with there being concern about blood loss in the pool. I looked at it and was concerned, but Mrs James remained stable so our main objective was to transfer her [to the labour-led ward] to listen to Callum’s heart.”

One of the issues with the pregnancy was the inability to get Mrs Ellis to the labour-led ward due to the speed of the pregnancy. Mrs Lewis explained that it came to a point where they just couldn’t carry out the transfer.

“We felt it was not appropriate to transfer Mrs James to the labour ward,” said Mrs Lewis. “There were strong urges to push, which is normal, and we felt there was no time.”

Consultant obstetrician and gynaecologist Dr Patrick Forbes, who wrote two reports on the case, said he entirely agreed with the decisions of the midwives.

Dr Forbes said: “It was absolutely correct to take Mrs James out the pool and I agree entirely that the appropriate action is to move the patient to the labour ward. However, one of the things I would dread in that situation is getting into the lift and the baby appearing.”

Dr Forbes explained how he was asked to look into two aspects of the delivery, firstly the merit, or not, of considering Mrs James as a low-risk patient, and secondly to examine whether Mrs James was in the right place, and if any alternative treatment was appropriate, and would have had any effect on the outcome.

“Mrs James did not identify to be considered high risk in the second pregnancy,” said Dr Forbes, “which meant it was suitable, if she agreed, for delivery in the midwifery unit. It was appropriate for her to stay on the MLU at Glangwili when she arrived.

"The descriptions by Mrs Ebba and Ms Leaves are much in line with standard practice.”

Pembrokeshire coroner Paul Bennett, giving a narrative conclusion, said: “Callum died as a result of hypovolemic shock brought about by an acute and severe loss of blood which occurred during the course of his delivery at Glangwili Hospital on May 5, 2016.”

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