“During the course of the inquest, I heard evidence that Zachary’s mother was permitted to…”

The coroner’s concerns

– (1) During the course of the inquest, I heard evidence that Zachary’s mother was permitted to enter a birthing pool to give birth in the known absence of a waterproof sonciaid. The lack of such equipment prevented the auscultation of the foetal heart rate. This was a matter I found causative of Zachary’s death. (2) I heard evidence that it was possible to have not permitted the birth mother to enter the pool and that it was possible to have removed her from the pool. I also heard evidence from an expert that it was ‘completely unreasonable to assume a woman in extreme pain would be able to manoeuvre herself above the waterline to enable auscultation with a non-water proof aid’. (3) I also heard in evidence that the Walsall Healthcare NHS Trust had no specific policy or directive to prevent birthing mothers entering the birthing pool in the absence of the correct equipment and would still offer this as an option even if the correct equipment was not available. (4) I heard evidence that a foetal heartrate could not be monitored in the absence of the correct equipment to do so, yet birthing mothers in labour at a vulnerable time are having the responsibility about a potentially unsafe birthing option presented to them. (5) I heard evidence during the inquest that the resuscitation undertaken by the 2 midwives involved in Zachary’s resuscitation was incorrect and inadequate and not in accordance with the resuscitation guidelines. The ratio of inflation breaths to CC should have been 3:1 instead of 15:1 and there was a period where no chest compressions were being carried out immediately prior to the arrival of a 3rd midwife. I also heard evidence that having been taken to hospital there was a period where Zachary’s airway was not managed during the transfer from the ambulance to the hospital. I found both of these matters causative of Zachary’s death. The inquest heard evidence that the two midwives involved in Zachary’s resuscitation had attended a non-mandatory training course only a matter of weeks before Zachary’s death which included an update of Newborn Life Support (NBLS). (6) I also heard evidence that most midwives will go through their whole career without experiencing a situation requiring new born resuscitation. I heard evidence that the mandatory training on NBLS was valid for 4 years and whilst the Walsall Healthcare NHS Trust had provided annual refresher training this was not guaranteed to continue. My concern is that there is insufficient frequent mandatory refresher training in new born life support skills.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2020-0035

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0