Tragic baby death sparks care reform

editorial image

ALL newborn babies at Nottingham’s hospitals are now checked every four hours by midwives, after a mother woke up to find her baby had died in her arms.

Kerry Pacey woke to find one-day-old Benjamin Reece Pacey had stopped breathing on February 3 last year, Nottingham Coroners’ Court heard.

She told the court her young son had been sleeping in the bed with her after she had breast-fed him at the Queen’s Medical Centre.

Before the incident, all healthy newborn babies at the hospitals were not routinely observed throughout the night and mothers were told about safe sleeping – where babies should sleep in the cot rather than with their mothers – after being discharged. This has now been changed.

All babies are now routinely checked every four hours and mothers are told about safe sleeping as soon as they are admitted on to a ward, the court heard.

In Benjamin’s case this may not have made a difference as he was being checked every four hours because he had streptococcus B – a bacterial infection which can cause serious illness in newborns.

Checks were recorded at 1.30am and 5.30am. But at just before 8am, Benjamin’s mother, of Broad Lane, Brinsley, said she was woken up by the noise of cleaners and raised the alarm because her son wasn’t breathing.

She claimed she was not aware checks had been done on him during the night and said she had fed her son at about 4am and then put him in the bed with her.

But, giving evidence, midwife Lindsay Beaumont said she performed checks on Benjamin, measuring his temperature, breathing and heart rate just before 5am.

She said: “Mum was in bed and appeared to be asleep and he was in the cot.

“I wouldn’t have done the observations on him if he was with mum, I would have put him back in the cot.”

Midwife Sarah Richardson came on duty in the morning and was there when the alarm was raised. She said: “When I spoke to Kerry afterwards she said she had woken to find Benjamin in bed with her.”

The cause of Benjamin’s death could not be determined and coroner Dr Nigel Chapman returned an open verdict.

He said: “We cannot change what has happened but I hope the improvements and changes made will give you some comfort.

“To go through nine months of the ups and downs of delivery and then the exhaustion, and then to find Benjamin died in your arms is horrendous for you.”