Hospital made series of mistakes before premature baby's death

A Welsh hospital made mistakes before the death of a premature baby, an inquest has found. Pontypridd Coroner's Court heard "opportunities were missed" by Prince Charles Hospital in Merthyr Tydfil before Penelope Pound died.

Civil servant Elinor Jones gave birth to Penelope on September 18, 2020, and she was pronounced dead later that morning. Assistant coroner Rachel Knight gave the cause of death as extremely premature delivery at 22 weeks and five days due to cervical weakness and amniotic fluid infection.

The mother said she had experienced persistent vaginal bleeding and abdominal pain from September 13. She attended the hospital three times over the next four days with concerns over the amount of blood she was losing. She gave her midwife a picture of a suspected show — which is when the mucus plug from the cervix comes away — but this was not properly escalated. The inquest heard that three days later Ms Jones was seen by a doctor who failed to notice membranes bulging from the cervix when there was still a chance the cervix could have been stitched. By the time she had a colposcopy later that day, there was no cervix left and any opportunity of saving the pregnancy was gone.

Ms Knight said it was likely an infection had been developing for "a number of days" before the birth. She added that after Ms Jones presented the midwife with a picture of what appeared to be a show, there was "inadequate passing up the chain", and the doctor who examined her on September 17 was not aware of the photo. The coroner said this experienced doctor had only looked at a "very abbreviated" version of Ms Jones' history and "likely did not realise" there had been a show days earlier.

This doctor had seen what she thought was a polyp — a typically benign growth in the cervix — but the coroner found she was "unconvincing" in her evidence. Ms Knight said there had been no sign of a polyp three days earlier and it was more likely than not that the doctor was actually seeing membranes bulging out. If the doctor had recognised the membranes and known about the photo Ms Jones had taken and her family history of mid-pregnancy miscarriages, then it "would have been reasonable" to escalate the concerns. Instead the doctor scheduled a colposcopy to look closer at the cervix later that day and the mum left the hospital to go shopping.

Ms Knight said: "Had this escalation occurred, it may have been possible to stitch Ms Jones and provide antibiotics to slow the process of dilation. It is likely the cervix quickly dilated and the pain felt by Ms Jones while shopping represented a moment of significance in that process. When she came back for the colposcopy there was no cervix left so there was no opportunity to stitch. Any opportunity to salvage the pregnancy would have been lost by that point. I find intravenous antibiotics may have improved the condition of the baby to some extent. I find Ms Jones went on to deliver Penelope on the morning September 18 and sadly she could not be resuscitated and died that morning."

The coroner also found there was a missed opportunity to keep Ms Jones in hospital for further observation over the previous days. Medics had relied on a speculum test which Ms Knight said was "too limited" to know the extent of the mother's bleeding and should have "checked what was coming out for a number of hours".

Ms Knight noted that Ms Jones later had a successful pregnancy in which she was stitched at 12 weeks due to "recognition of an inherent cervical weakness". But the coroner said there had not been enough evidence for her to be categorised as high-risk in the early stages of the previous pregnancy.

Recording a narrative conclusion, Ms Knight said Ms Jones had presented with ongoing vaginal bleeding from September 13 and that both the infection and cervical weakness had contributed to the extreme prematurity which caused Penelope's death. The coroner added: "A clinician did not identify the bulging membranes at a time when it may have been possible to stitch the cervix and administer antibiotics."

Ben Davies, representing Penelope's family, said during the hearing: "The concern the family have is that Ellie [Elinor Jones] wasn't being listened to. More weight was placed on what clinicians and midwives recorded than getting straight to the source of the information and asking her themselves."