A mother has told an inquest how she was dismissed after raising concerns about severe discomfort and being physically ill while undergoing an induced labour that resulted in the death of her newborn son at just four days of age.

The infant, named Jac Arthur Lewis, was delivered via emergency caesarean section at the Grange University Hospital in Cwmbran during November 2024.

The four-day inquiry commenced at Newport Coroner’s Court to investigate the circumstances surrounding the baby’s death, with particular attention to the treatment provided to his mother Ceri Lewis during the scheduled induced labour. Due to her type two diabetes and history of two prior pregnancy losses, the pregnancy had been classified as high risk.

In evidence presented by Gwent area coroner Rose Farmer, Mrs Lewis described arriving at the hospital with her husband Matthew at 11.30am on November 1.

A pessary was administered at 1.10pm to initiate contractions, though by approximately 5.30pm she had begun vomiting, thirty minutes after receiving codeine for pain relief that had been preceded by paracetamol shortly before 2pm.

At 6.30pm, Mrs Lewis told a midwife she was experiencing agonising discomfort and was unable to urinate, yet an hour later she reported still being in considerable distress. Fifteen minutes after this, she informed a midwife the pain was so intense she could not determine foetal movement.

Following an anti-nausea injection at 9pm, Mrs Lewis recalled a midwife sounding an alarm and calling for assistance before she was wheeled out on a bed, subsequently waking to find staff staring at her rather than offering comfort.

The emergency caesarean procedure commenced at 9.30pm, with baby Jac delivered with a dangerously low cardiac rate of just 60 beats per minute, appearing pallid and requiring resuscitation on two separate occasions.

During the early hours of the following day, another midwife named Dianne Jayne Morgan reportedly informed Mrs Lewis that her membranes had ruptured, something the mother disputed.

Mrs Lewis further described being distressed by the midwife’s questioning. She said the midwife asked whether she had been asked to monitor the infant’s heart rate. This deeply upset her as she felt she was being held responsible, and her mother intervened stating that monitoring was staff responsibility, not hers.

She said she sensed a complete absence of empathy. Dianne Jayne Morgan responded by telling her to consult the NICE guidelines and that they had not acted inappropriately.

Mrs Lewis stated she had documented her experiences upon returning home and noted that medical staff had failed to acknowledge concerns raised by herself or Matthew regarding her condition.

She expressed that she felt terribly abandoned. The personnel demonstrated no regard for her or her firstborn child.

She said they were informed their discomfort was expected and made to believe they were exaggerating. Had they heeded her calls for assistance rather than disregarding them, Jac might still be with them today.

Mrs Lewis additionally acknowledged the exceptional medical attention provided by physicians and nurses who treated Jac after his delivery.

In his own account, also presented by Ms Farmer, Matthew Lewis described being summoned back to the hospital shortly after 9pm but only became aware of the seriousness of the situation upon overhearing medical staff discussing the case outside his wife’s room.

He stated that when midwife Ms Morgan subsequently spoke with him, his wife, and her mother, it was evident that shortcomings had occurred as she repeatedly stated they had acted appropriately and he believed she was attempting to manipulate Ceri’s recollection. They were all struggling to process events and he was astonished by her conduct.

Ms Morgan testified during the proceedings and maintained confidence in her documentation of Mrs Lewis reporting cramp-like discomfort, attributing this phrasing to the patient’s own description, despite Mrs Lewis contesting use of the term.

The midwife, possessing 35 years of professional experience, insisted on recording the patient’s own wording in her accounts. She was not examined regarding her statements to Mrs Lewis after the birth.

Three additional midwives who attended to Mrs Lewis from her appointment arrival until the emergency surgery also provided testimony, describing their involvement but acknowledging they were unaware she was experiencing severe pain.

Questions were raised regarding their protocols for monitoring foetal heart activity and why such monitoring was not performed until after 9pm, despite the initial thirty-minute assessment beginning at 1.10pm.

The court also heard that while NICE, the NHS advisory body, specifies EGC cardiac monitoring solely every twelve hours, the Aneurin Bevan University Health Board, which manages the Grange facility, has since implemented revised protocols requiring six-hourly monitoring for high-risk pregnancies.

The inquest remains ongoing.