Inquest told of regrets over care after baby's death
A midwife has told an inquest she regrets not getting a mother out of a water pool during a complicated labour after her baby boy died hours after being born.
Former midwife Patricia Cronin also revealed at Black Country Coroner’s Court that the last working waterproof heart monitor, or sonicaid, had broken during the same evening Zachary Johnson was rushed from the Walsall Manor Hospital’s midwifery-led unit to the main hospital.
Mother Joanne Johnson, 34, of Lichfield Road, Willenhall, suffered complications during her pregnancy on October 15, 2016, and it was revealed during the opening day of the inquest on Monday his heart had not been monitored for more than half an hour just prior to his birth.
Babies should be monitored every 15 minutes during stage one of labour and then every five minutes during stage two.
Further problems arose that night when a support worker called in sick on her way to unit, leaving Mrs Cronin and midwife Junie Drummond to look after two ladies in labour.
And when Zachary was found to not be breathing once he had been born, it was discovered a resuscitator machine had run out of oxygen.
Mrs Cronin – who had been a midwife for 15 years before being sacked in 2017 following Zachary’s death – told yesterday’s inquest a quick turnaround during handover meant she had no time to call for an extra support worker or to tell Mrs Drummond about the lack of waterproof sonicaids.
Mrs Cronin later explained there had been previous incidents at the MLU when there had been no such aids working, adding “it was not an isolated occasion”.
Miss Julie-Anne Luck, representing mother-of-two Mrs Johnson and her husband, Steven, 36, questioned Mrs Cronin over the actions she had taken that night.
She said: “You are an experienced midwife. You know in the birthing pool is a lady who needs to be monitored by a waterproof sonicaid, you know the waterproof sonicaid is broken, you needed to relay this information. So why on earth did you not say, ‘let’s get this lady out?’.”
Mrs Cronin said at first Mrs Johnson had been able to lift her abdomen out the pool to be monitored, which meant she could use a non-waterproof aid. Miss Luck added: “You said you twice saw Mrs Drummond was still not being able to check the heart rate.”
Mrs Cronin replied: “It is my regret I didn’t tell her to get out of the pool. I was aware she was in the second stage of labour but didn’t know she was experiencing any problems.”
Mrs Cronin also explained she had never before seen a baby born in Zachary’s condition, adding: “We’d never had a real emergency.”
Zachary was eventually rushed to Walsall Manor Hospital but died of acute severe hypoxemia, on October 16, 2015, after his parents agreed to turn off his life-support machine due to severe brain damage.
The three-day inquest ends today.
