He did also say that a three hour period where Jack was ineffectively intubated by a paediatrician also contributed to his death just 14 hours after he was born.

You can read about the verdict of the inquest here. 

Since that verdict was delivered, baby Jack's parents, Andrew and Jesyka Tually, have issued a statement which Express has reproduced in full below: 

Statement issued by baby Jack Tually's parents, Andrew and Jesyka Tually: 

"We have campaigned for truth and justice for our son, Jack, for nearly five years. We have encountered resistance, every step of the way, from the same institutions and individuals that were charged with the protection of our son’s life or with the duty to impartially investigate his death. But for the actions of one brave whistle-blower at the PEH, none of the facts surrounding our son’s death would have surfaced and would have remained covered up forever.

"Finally, nearly five years after Jack’s death, we returned to Guernsey this week to attend the coronial inquest into his death. No family should ever have to wait so long for answers, a wait which has only served to compound our grief. There is clearly a need to reform the coronial process to ensure that it operates more transparently and efficiently.

"Expert evidence given at the coronial inquest – evidence that was commissioned by theinstitutions we hold responsible for Jack’s death – has given us some limited clarity as to thecause of Jack’s death and the circumstances surrounding it. The expert evidence recorded a litany of harrowing failures in midwifery, obstetric and paediatric care as well institutional failings in clinical care, management and governance, many of which were not explored given the court’s decision that it did not want to decide the facts or hear from witnesses who were there at the time Jack died. Whilst one of the experts at the inquest concluded in his report that all the failings, “in all probability, contributed in some way to” Jack’s death, because of the legal technicalities employed by the inquest, it has not been possible to directlyattribute the failings in care to Jack’s cause of death. We will always feel those failings in care, whether individually or collectively, contributed to the loss of our beloved son.

"The failings in care by the midwives have been reported by the media previously and those midwives have been struck off or suspended. However, the expert evidence before the inquest identified other failings in care. Specifically, Mr Carl Jensen, the consultant obstetricianinvolved with Jack’s delivery, was alleged by the experts to have failed to properly assessJack’s case and performed a “possibly dangerous instrumental delivery”, causing an “extreme scalp” trauma to Jack which lead to haemorrhage. Dr Susan Eckhardt, the consultant paediatrician involved with Jack’s postpartum care, was alleged by the experts to have failedto diagnose Jack’s condition, failed to seek help and failed to correctly intubate Jack three times. Jack was deprived of oxygen for the first eight hours of his life. The expert evidence at the inquest confirmed that Jack’s condition could have been survivable had he received proper treatment. None of the doctors admit these failings identified by their peers/experts. It is impossible to see how the public interest could be served, or health services improved, in the face of such arrogance.

"At the inquest, an expert also explained that UK hospitals are ranked as tertiary (being the most advanced), secondary and local (being the most basic). In the opinion of that expert, the standard of neo natal emergency care in Guernsey falls below that of a local hospital in the UK, i.e. lower than the lowest standard of care in the UK. One expert described theenvironment at the PEH in Guernsey at the time as “inherently dangerous”. We can only hope that Guernsey’s politicians, senior health officials and individual clinicians take heed ofJack’s case and acknowledge the limitations in care on the Island and implement better processes and procedures to ensure that complex medical situations can be managed with appropriate support and assistance from the larger/more experienced hospitals in the UK. Such arrangements will foster better medical care and a safer culture for Island families. Indeed, as the evidence before the inquest found, had such arrangements been in place and/orused in Jack’s case, he could be alive today and celebrating his fifth birthday."

The President of the Committee for Health and Social Care, Deputy Heidi Soulsby has also issued a statement (pictured above outside court this morning):

"On behalf of the Committee for Health & Social Care, I’d like to say that we welcome today’s verdict. It has been 5 long years since Baby Jack died, and the intervening time has weighed heavily on all concerned, but above all of course, on his parents.

"And I would like to take this opportunity to publicly and wholeheartedly express my deepest sympathy to them. I know that losing a child is every parent’s worst nightmare and I can’t imagine just how difficult it has been for the family.

"I understand that it may be of little comfort to Baby Jack’s parents, but, as is widely known, this tragic case sparked a process of review, investment and work with the Nursing and Midwifery Council that brought many changes to the way we deliver these vital services. Our maternity services today are not the same as they were in 2014 as a result.

"While I am pleased that the community has been, and can continue to be, reassured about the improvements we have made and the standard of care we offer, those achievements in recent years do not change the past, for which I am sorry. I just hope today’s verdict will help them obtain some sort of closure, if at all possible."

Pictured top: Loveridge Ward at the PEH.