A newborn infant who died four days after an emergency caesarean section at a major hospital in Gwent succumbed to natural causes, a coroner has concluded.
The inquest heard that the mother, Ceri Lewis, believed midwives dismissed her concerns after she reported intense pain and nausea following her arrival at the Grange University Hospital in Cwmbran for an induced labour.
Her pregnancy was deemed high-risk due to pre-existing type two diabetes and a history of two miscarriages, meaning a consultant oversaw her care.
Her son Jac Arthur Lewis required resuscitation on two occasions following his birth at 9.29pm on November 1, 2024, before being transferred to intensive care treatment.
Gwent coroner Rose Farmer determined the infant passed away at the hospital on November 5 from perinatal asphyxia, which occurs when a baby’s brain receives insufficient oxygen, in conjunction with an undersized placenta.
After more than two days of testimony, Ms Farmer stated her function was not to evaluate whether treatment could have been enhanced but to determine whether any clinical incidents necessitated remedial measures that were not implemented.
She found no failures in care or treatment that contributed to Jac’s death, adding that even if such failures had existed, establishing causation would not have been possible.
The coroner noted that consultant paediatric pathologist Dr Andrew Richard Bamber’s evidence indicated the reason for the oxygen deprivation could not be determined, though the severely small placenta possessed minimal capacity to withstand additional strain and represented a significant contributing factor in the infant’s death.
Delivering her conclusion, Ms Farmer stated she had determined Mrs Lewis was not in active labour during the appointment.
She also accepted the account of the midwife responsible for Mrs Lewis’s care when she arrived at the hospital at 11.30am on November 1, that she had not been informed about the vomiting. The midwife outlined the steps she would have undertaken had she known about the vomiting during the induction process.
A second midwife who took over care during the evening shift responded after Mrs Lewis reported vomiting, and Ms Farmer stated she accepted the reasoning behind the decision to address the mother’s discomfort before checking for the foetal heartbeat during an examination just before 8pm.
Mrs Lewis was taken to surgery for the caesarean when the midwife checked for the heartbeat at 9.13pm.
The coroner stated both midwives had exercised clinical judgement and had documented their responses to Mrs Lewis’s pain reports with observations. Ms Farmer found the pain was not clinically significant and both midwives considered it consistent with the induction process.
She further stated it was appropriate for the second midwife to have requested Mrs Lewis to monitor her baby’s movements for 10 minutes after she reported being in such severe pain that she could not determine whether her baby was moving.
Ms Farmer indicated she did not consider a prevention of future deaths report necessary, as she was satisfied with measures implemented by the Aneurin Bevan Health Board following its serious incident investigation, including increasing foetal heart rate monitoring during induction in high-risk pregnancies from every 12 hours to every six hours.
The coroner acknowledged the challenges faced by Jac’s parents Mrs Lewis and husband Matthew in recalling events during such a stressful period, and while she noted midwife records were not always completed at the time of events, she accepted this was not always feasible.