C-section delay did not cause high-risk baby's death - coroner

A baby boy who died eight days after an emergency Caesarean section could not have been saved despite "missed opportunities" to deliver him earlier, a coroner has concluded.

Richard George Sajan was born on 3 December 2024 after his mother Jossymol George, 37, attended Blackpool Victoria Hospital concerned about reduced foetal movements.

Richard, described as the "most precious" child by his parents, had been considered a high-risk pregnancy after his mother developed gestational diabetes, but medics initially failed to recognise the danger he was in.

Experts told Blackpool Coroners' Court the failure likely did not contribute to his death, and a conclusion of natural causes was recorded.

The inquest heard Richard had died from a combination of a lack of oxygen to the brain, low blood sugar and multi-organ damage, with maternal gestational diabetes listed as a secondary cause.

Assistant coroner for Blackpool and Fylde Louise Rae said: "I accept the evidence of the experts that the injury was already established by the time Richard's mother presented to hospital, and was not reversible."

Earlier in the inquest, Jossymol George and Richard's father, 41-year-old Sajan Thomas, said in a statement that they had been "over the moon" to be having a third child.

However, they said after he was born medics did not make it clear that their baby was seriously unwell and there was "no real urgency" among staff.

The court heard the maternity team was aware his mother had gestational diabetes and they knew that both her previous children had been delivered by Caesarean section.

The couple said they were "completely devastated" by their son's death.

The court heard their six-year-old daughter carries a doll that she has named Richard and their eldest son, 10, had written in his diary about his baby brother's death.

In her concluding remarks, the assistant coroner said Jossymol George attended the hospital shortly after 01:00 GMT and her baby's heart-rate was monitored using a cardiotocography (CTG) machine.

A midwife, Debbie Gornall, had tried several times to raise the alarm about what she described as "concerning" CTG readings to the hospital's obstetric team and senior members of the midwifery team.

However, Richard was not delivered until 06:09.

The court heard medics failed to interpret the CTG findings in the context of Jossymol George's high-risk pregnancy, reduced movements and previous scan results.

Richard was transferred to the Royal Preston Hospital but his condition did not improve and a decision was made to place him on end-of-life care.

He died on 11 December 2024.

Rae said: "Whilst issues have been identified in the interpretation and escalation of CTG findings and the timing of delivery, which should have been earlier, I am not satisfied on the balance of probabilities that earlier delivery would have altered the the extent of Richard's injury, his subsequent clinical course or the ultimate outcome."

She said she had also reviewed an "action plan" written by Blackpool Victoria Hospital managers to address the failings identified after Richard's death, and was satisfied it was not necessary to issue a Prevention of Future Deaths report.

She added: "I heard moving evidence from Richard's parents about their anticipation of his arrival, the love they have for him, the hopes they held for his future.

"Richard's loss has had a profound impact on his family, and I'd like to end now by offering my sincere condolences to his parents and to his wider family."

After the hearing the family's solicitor, Eleanor Rostron, said: "The hospital had a duty of care to save Richard's life. The obstetric doctor on shift failed to recognise abnormal CTG results in a high-risk mother and quickly proceed to a life-saving Caesarean delivery, even when the midwives caring for Richard's mother were raising the alarm."

She said the family had instructed her to pursue a medical negligence claim against The Blackpool Teaching Hospitals NHS Foundation Trust.

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