Twin baby died after Caesarean section delay, inquest hears
A mother lost her baby girl after medical teams failed to diagnose problems during a labour in which she also gave birth to a stillborn son, an inquest has heard.
Nicola Singleton, then of Sully in the Vale of Glamorgan, needed an emergency Caesarean section but faced a two-hour delay at hospital in Llantrisant.
Son Reuben was stillborn and surviving daughter Esme died the next day.
Cwm Taf Health board accepted failing in its standard of care and apologised.
Coroner Louise Hunt said there was a considerable delay in doing the Caesarean section because the seriousness of Mrs Singleton's condition was not appreciated.
The two-hour delay in delivering Esme was more than enough for the damage to have been done, said the coroner.
The inquest at Aberdare, Rhondda Cynon Taf, was told that Mrs Singleton, 49, was admitted to the University Hospital of Wales in Cardiff suffering from severe stomach pain when she was 30 weeks pregnant.
But a shortage of cots meant she had to be transferred to the Royal Glamorgan Hospital.
When she arrived at the Royal Glamorgan, midwives could only detect one heartbeat instead of the two there should have been.
Mrs Singleton's husband, Ian, 50, broke down in tears as he described seeing an ultra-scan of the twins before his wife's operation.
"I could see that four heart valve chambers had stopped and the others were starting to slow," he said.
Later he was told that Reuben had died and that Esme was "very poorly".
Esme showed no signs of life but began breathing after 22 minutes of resuscitation.
She had suffered severe brain damage however, and her parents agreed to switch off her life support machine the following day.
The inquest heard that warning signs were ignored by midwives even though Mrs Singleton was in great pain.
Consultant gynaecologist Hatel Tejura told the inquest: "There was no uterine activity and no sign of a foetal heartbeat.
"The alarm bells should have been ringing then."
The inquest heard that the couple, who now live in Wiltshire, had lost a son at the age of 16 from a brain haemorrhage.
They later embarked on a programme of IVF to start a new family.
The inquest was told the health board had accepted failing in its standard of care and offered its profound apologies to the family.
The coroner recorded a narrative verdict saying: "Esme was well at 12.40pm - it is most likely there was a critical event then with things changing radically but not being appreciated by the medical staff.
"They have acknowledged that today.
"Because it was not appreciated that she was in serious difficulties there was a considerable delay in doing a Caesarean section.
"Esme was not delivered for two hours - more than enough for the damage to have been done.
"She died from brain damage caused by the rupture which went undiagnosed in labour resulting in delay in the delivery."
The inquest heard that measures had been put in place at the hospital to make sure that a similar tragedy did not happen in the future.
After the hearing, Mrs Singleton, 49, said: "This happened three years ago but the pain is still there and will never, ever go away."
Mr Singleton, a factory manager with Honda, said: "Heart monitoring showed that Esme was well at 12.40 - if the operation had been performed then she would have been alive today.
"We feel that her death was a mixture of incompetence, negligence and a cavalier attitude."
The couple's solicitor Chris Inskip said: "Nicola and Ian have endured a difficult and traumatic time since the death of their twins.
"They sincerely hope that lessons have been learned from the tragedy but the legal case against the hospital for negligence continues."