Coroner finds that hospital care given to mother and baby was ‘nothing short of shocking’

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An inquest has found that ‘shocking’ mistakes contributed to the death of a baby at the Queen’s Medical Centre in 2018.

Kaylan Coates, son of Hayley Coates, suffered a fractured skull during a forceps delivery and tragically died from a hospital infection a week later. The Coroner found that staff had not consulted his mother properly and had failed to spot that her baby was in distress.

After a healthy pregnancy, Miss Coates attended the Nottingham hospital to be induced. Two days later she requested a Caesarean section, however this was not passed on to the appropriate doctors. As the birth progressed, both doctors and midwives failed to address the baby’s heart rate drastically changing. The readings from Kaylan’s heart rate monitor were miscategorised on more than one occasion and as a result the distressed baby was not given the treatment that he so desperately needed.

Had Miss Coates been consulted properly and her request for a Caesarean section escalated, it is likely that her baby would’ve been delivered that same day and before Kaylan’s condition had deteriorated. The Coroner stated that this would “probably have avoided his death.”

When preparing for the forceps delivery, maternity staff failed to correctly identify the positioning of Kaylan. As a result, he suffered a fractured skull, associated bleeding and brain damage due to the lack of oxygen.

The baby was placed on a ventilator and given antibiotics. Although he at first responded well to treatment, staff failed to recognise that he had caught a serious infection. Kaylan sadly died just a few days later.

Miss Coates has suffered tremendously as a result of this negligence and had not understood why her baby had died up until now.

Michele Benjamin, a chartered legal executive in the medical negligence team at Ashtons Legal, comments: “It is truly sad and disappointing that so many mistakes were made surrounding the birth of baby Kaylan. Had the issues been identified in a timely manner, the death could have been avoided and Kaylan could have been delivered safely. The medical negligence team at Ashtons are becoming more and more familiar with cases whereby early intervention is crucial in terms of resolving medical complications. The conclusion of the inquest is a small positive in such a tragic situation. Miss Coates now has some form of closure in knowing the reasons behind the death of her first child.”


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