Jasper Brooks: Inquest into the death of baby finds that he died due to hospital’s neglect

Jasper James Brooks died on 15 April 2021 at the age of 23 hours. An inquest has found that Jasper died as a result of gross failures by treating staff at the Darent Valley Hospital in Kent. The coroner concluded that the catalogue of failures by midwives and doctors at the hospital, amounted to neglect and that Jasper’s death was “wholly avoidable”. The family are represented by Ashtons Legal.

During her first pregnancy, Jasper’s mum, Phoebe, had suffered a placental abruption. A very serious condition which causes the placenta to detach from the wall of the womb. This had been managed appropriately the first time and Phoebe was booked in for a planned Caesarean section with Jasper due to the risk of giving birth vaginally.

When Phoebe went into labour prematurely, she attended Darent Valley Hospital, where staff did not believe she was in established labour. Staff opted not to perform a Caesarean section overnight, and instead suggested the procedure take place the next morning, going against a plan, without seeking consultant input and against protocol. The family were told this was because there would be more staff available despite no issues with acuity being found. Both Phoebe and Jasper’s dad, Jim, repeatedly raised concerns with staff and were not taken seriously. Vital checks were not carried out on Phoebe or Jasper.

The coroner found that this change in plan unacceptable and that the doctor misunderstood the situation, and that Phoebe was not able to exercise choice at this time. This failure to understand the risk Phoebe was in was critical, and there was a missed opportunity to deliver Phoebe by c-section sooner and as planned. The coroner reinforced his concerns that the doctor did not seek consultant reassurance and a sense of arrogance that the doctor assumed the Consultant would agree with him anyway.

Phoebe was, in fact, developing a placental abruption. She was bleeding and her notes show that she was ‘bleeding loads’, but this was not concerning, nor her increasing contractions, significant sickness and pain. Instead, she was told to go for a walk and later have a bath. What Phoebe needed was proper monitoring and a plan to deliver Jasper urgently.

Unfortunately, this did not happen and Phoebe went on to deliver Jasper vaginally, who was born in a poor condition with no neonatal staff present to perform a resuscitation. The resuscitation that followed, in the family’s own words, was ‘shambolic’.

27 minutes after Jasper was born, Phoebe and Jim were told that because no heartbeat was present, they would end resuscitation efforts. However, shortly after this, Jim shouted out for Jasper and Phoebe touched Jasper and a heartbeat was found. Jasper was taken away for tests. Following these tests, Jasper’s parents were told that treatment would be futile and they would proceed with palliative care. A decision which was incorrectly made by a single Consultant, without properly consulting the family.

The Consultant had contacted Medway Hospital, where cooling could have taken place. The Consultant was advised to discuss options with the family and to keep them updated if Jasper improved. In fact, Jasper was responding to treatment despite the fact that he was receiving little care and Phoebe had to beg to express and feed Jasper.

There was no further review, there were no discussions with the family and they were placed in a room with no windows to await their son’s death. The coroner found the neonatal consultant to have both misinterpreted and misrepresented the advice they had been given from Medway. The coroner found that cooling would have been a reasonable option, yet this was not presented to the family as an option. The coroner went so far as to say the consultant withheld vital information from the family.

What followed was a period of investigation where the Trust failed to follow the Duty of Candour which was accepted in evidence at the Inquest. The family should have been told what had happened and it should not have been left to the Inquest and the coroner to find a catalogue of errors in care and to provide even basic medical attention, which amounted to neglect.

In addition, the coroner highlighted the following failures in the care provided by the Trust:

• There was a failure to recognise that Phoebe was in established labour
• At the point of blood loss being discovered, this should have been escalated, proper monitoring and review should have taken place and this would have led to an earlier delivery via C-section
• Changes in plans were inappropriate, against protocol and reasoning
• Phoebe and Jim were not listened to by staff at the hospital
• Concerns raised by Phoebe and Jim, such as vaginal bleeding, were played down by staff
• There was a failure of staff to appreciate the escalating condition of Jasper, where his delivery should have been expedited and a neonatal team present at his delivery, where it was not on both accounts
• Certain members of staff acted outside the remit of the professional obligations with little regard to protocol and proper process
• Jasper’s care was prematurely withdrawn, with this decision being made outside of national guidelines.

The coroner concluded that Article 2 of the Human Rights Act was engaged, and stated: “I will express in my narrative conclusion that the decision to withdraw care was taken prematurely and that this caused his death”.

Bethany Kyle, Solicitor in the Medical Negligence team at Ashtons Legal, who represents the family, comments: “The findings of the inquest will come as no surprise to Jasper’s parents, who already knew they had been desperately let down by the Trust. They have fought hard to highlight the failures in Jasper’s care. Sadly, no outcome at the inquest will bring back their son, whose death could and should have been avoided. We hope the Trust will consider these findings very carefully and implement changes to avoid causing such devastating harm to families in the future.”

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