Five years later: answers due on how Baby Jack died

Tuesday 15 January 2019

One of Guernsey's Judges is expected to deliver a decision later this week, on how baby Jack Tually died, after he heard evidence from three medical experts - five years after the little boy died shortly after his birth.

Judge Philip Robey has been presiding over the inquest, which initially opened in 2017 but resumed on Monday, to try and answer the question of how baby Jack came to die just 14 hours after he was born.

The court has heard a number of stories of potential clinical negligence, and also accounts of how all three of the medical experts called to give evidence believe baby Jack died from PPHN - a circulatory problem where new born babies struggle to breathe independently with their own lungs.

It is now down to Judge Robey to decide whether it was negligence that caused baby Jack's death, or whether the PPHN, and subsequent hypoxia, was the cause.

Baby Jack died just 14 hours after he was born, but it has taken five years since then to get to this point in the Inquest, which opened in October 2017.

When baby Jack died in January 2014, he was just 14 hours old. After a not-so-simple labour period, in which he was delivered by an Obstetrician using instruments, he was deemed to be a healthy baby boy, but just three minutes after that assessment he was struggling to breathe. 

Both the clinical decisions made before that point and after have been under scrutiny in the court, and each expert was asked how every decision might have changed the outcome. But it was also made clear that this inquest was not being held to allocate blame or bring anyone to account, rather, just to find out why baby Jack did not survive. 

None-the-less, questions were raised over the decisions made by the Obstetrician, who caused "trauma" to baby Jack during the delivery, and also of the paediatrician, who in one instance failed to intubate baby Jack a number of times.

One of the three experts, Dr Mark Ashton, told the court his opinion was that the condition was survivable if the correct care was given: "it is difficult to be certain but my opinion is that such an infant would have survived if in a tertiary care unit [in the UK], but the geographical location of Guernsey must be a mitigating factor."

Dr Ashton also told the court the traumatic delivery "could have caused" the PPHN in baby Jack, which both he and Professor Walker, the obstetrics expert, agreed was the most likely cause of death. 

Deputy Heidi Soulsby, President of HSC, has assured people the current standard of maternity care is much better than it once was. 

Now, it will be down the Judge Robey to deem whether that was the case. He is expected to hear closing statements from all of the Advocates involved in proceedings on Thursday, and will deliver a judgement after that. 

But there has already been far reaching impact as a result of baby Jack's sad death. Since things first came into the public eye in 2014, the Nursing and Midwifery Council conducted a full scale review into the services the Loveridge Ward were offering, which ended with a damning conclusion of poor performance. Since then, four midwives have been struck off - two of them were directly linked with this case. Health & Social Care also insist wide sweeping improvements have been made, but the future of the doctors involved is yet to be seen.

To read HSC's latest statement, click here. More to follow later in the week. 

Pictured top: The PEH, where the Loveridge Ward is.