‘No learning from tragic event’: coroner criticises locum after newborn’s death
PUBLISHED: 19:45 09 July 2020 | UPDATED: 16:24 10 July 2020
A coroner will write to a medical watchdog over concerns about a locum registrar involved in the birth of a stillborn premature baby.
Kobi Wright was delivered at 34 weeks in the James Paget University Hospital (JPUH), Gorleston, on March 3, 2019, at around 3.30pm through Caesarean-section.
The emergency operation was carried out by on-call consultant Tamanrit Johal after a failed attempt at a forceps-assisted delivery by experienced locum registrar Dr Fakher Gendy.
Following the three-day inquest, senior coroner Jacqueline Lake made a Regulation 28 order and said: “I do have concerns about training. As far as he [Dr Gendy] is concerned the only concern was with record keeping. There has been no learning from this tragic event despite his reflection. I propose writing to the General Medical Council expressing that concern.”
She made no criticism of Miss Johal and was satisfied the JPUH had taken action since Kobi’s death and taken the matter seriously.
The inquest heard Kobi’s mother Tracey Goode had been admitted to JPUH on the evening of March 1 after her waters broke.
Ms Johal told the inquest she was telephoned by Dr Gendy, an experienced registrar, at 1.57pm on March 3 after he wanted to deliver Kobi due to decelerations of his heart rate, which Miss Johal agreed with.
But Dr Gendy said that was not the case and wanted to deliver because Kobi was a pre-term baby, the amount of time since Ms Goode’s waters had broken and that labour was not progressing.
Dr Gendy told the inquest Kobi’s head was delivered easily with forceps at 2.44pm but his body could not be born and the cervix retracted in size around his neck. The head remained visible for 10 minutes.
When Kobi was born, medical staff attempted to resuscitate him for 20 minutes before he was pronounced dead.
Dr Gendy, who had completed relevant online training, said: “It made me feel very sad and depressed months afterwards.”
MORE: Consultant may have held off delivery premature baby, inquest hears
Kirsty Cater, maternity and gynaecology risk and governance manager at the JPUH, said: “We have made good positive changes since this incident. We will continue to work collaboratively with the consultant team to achieve that. At the heart of it all is the safety of women.”
She added that the midwifery unit was improving its communication and culture.
Juliet Stevens, representing Kobi’s family, said: “No evidence has been provided on any steps to check or verify training. The family are of the view the trust had no systems to check the locum doctors they employ are adequate, which could bring a risk to life from mother and baby. Evidently Dr Gendy fell through the net and the parents do not wish what happened to Kobi to happen again.”
Jeremy Loran, representing the JPUH, said: “There is an executive lead for HR which is looking into matters of checks. There are checks and locums do have to be approved. The next steps are that any locum would be expected to complete their training. There are clear safeguards in place.”
The medical cause of death was pre-term still birth, complicated instrumental and Caesarean-section delivery and prematurity.
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