The family of a baby who died just hours after her birth have told of their heartache, following an inquest which identified a catalogue of errors by hospital staff.

Bonnie Webster was born in the Queen Elizabeth Hospital (QEH), in King's Lynn, on February 9 via an emergency C-section after her mother suffered a placental abruption. 

Eastern Daily Press:

Her short life ended the following day at the Norfolk and Norwich University Hospital (NNUH), where she had been transferred for intensive care.

After the inquest identified series of mix-ups in her treatment at the QEH, Bonnie's parents said their family would "never be whole".

The Lynn hospital reiterated its condolences to the family and said lessons had been learnt from the tragedy.

The inquest heard that mother Megan Webster was admitted to the QEH from her home in Mileham after waking up in constant pain.

Throughout the pregnancy - her second - she had been a patient of the NNUH and was due to give birth there.

But due to the A47 being closed at the time she was taken to the QEH instead.

On admission, the hospital struggled to bring up her electronic record - but this would just be the beginning of the complications.

The inquest heard that over the course of her treatment a number of things went wrong, including:

  • An operating theatre not being properly prepared - including a resuscitation machine not being equipped with an oxygen tank
  • A replacement oxygen tank arriving three-quarters empty
  • Medical equipment being dropped and broken, leading to further delays while replacements were sought
  • Miscommunications between staff leading to her emergency C-section being given a lower level of urgency
  • Antibiotics ordered for the tot not being administered

Emmanuel Mamah, the registrar who performed the caesarian, told the court: "I panicked - things were going really wrong.

"It was very chaotic and very difficult for me."

The technical difficulties with the theatre meant there was a delay of around 25 minutes between Mrs Webster being brought in and the operation starting.

Dr Mamah added that afterwards, he had sought out Mrs Webster to personally apologise for the complications.

Giving a narrative conclusion, senior coroner Jacqueline Lake said she had "many concerns" about what she described as a "stressful and traumatic" experience for Mrs Webster and husband Lee.

Eastern Daily Press: Senior coroner Jacqueline Lake. Photo: Bill Smith

She said she was particularly concerned that hospital staff had not given Mr and Mrs Webster a clear enough picture of the situation when asking them to make a decision about whether to opt for a C-section - another stalling factor in the delivery.

However, she said it could not be said for sure whether Bonnie would have survived without the issues.

She said: "The evidence does not reveal the extent the delays before and after the birth contributed to her death.

"There are clearly many concerns that have been raised during the course of this inquest.

"I have ongoing concerns that in such distressing and traumatic situations the options should be made very clear.

"It has to be absolutely clear so patients can make educated and informed decisions."

In a statement issued following the hearing, Mr and Mrs Webster said: "Our world has shattered following the death of our much-loved baby girl, Bonnie.

"Due to the circumstances surrounding her death, we have not had the chance to grieve or process our loss.

"Our family is never going to be whole and the future we hoped for has been lost.

"Mistakes have been made and now is the time for changes to be put into action.

"We would hate for any other family to go through our pain - our beautiful Bonnie will forever be in our hearts."

Helen Blanchard, interim chief nurse at the QEH, said: "On behalf of the Trust, I reiterate our condolences to Bonnie’s parents and family.

"A thorough investigation into the circumstances of Bonnie’s condition at birth was carried out by the Healthcare Safety Investigation Branch. The Trust cooperated fully with this investigation and with the inquest process.

"I would like to offer an assurance to Bonnie’s family we have learnt through the investigation, specifically the importance of clear communication with families and more effective communication between healthcare teams."