Baby Zac might have lived had he been seen by neonatal team, Leicester inquest told
A newborn baby who died of pneumonia might have been saved had he been referred to neonatal experts before being discharged from hospital, an inquest heard.
Zac Waugh was less than 24 hours old when he died on February 15 last year.
An inquest into his death, held at Leicester Town Hall yesterday, was told he had a high temperature of 38.1C when he was checked by a midwife at Leicester Royal Infirmary at about 11.15pm on February 14, two hours after he was born.
However, he was not referred to the neonatal team.
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Zac's mother, Beth Bradshaw, herself a trained nurse, told the court she raised concerns about Zac's breathing, skin colouring and the fact he was unsettled on "three or four" occasions prior to their discharge.
When taking to the stand, the coroner told her not to worry if she could not remember everything that happened following Zac's birth.
She told the court: "They were the only hours I had with my boy, so I remember them."
Miss Bradshaw told the hearing Zac was "irritable, crying and just didn't seem happy" and described his breathing as "snuffly".
She said she became so worried about his crying waking up other mums and babies on her ward she went to sit with him in a corridor outside.
Miss Bradshaw then told the court how Zac stopped breathing within hours of arriving back at their home in Oadby.
She managed to revive him initially, but as she and fiance Sam Waugh were preparing to take him to the GP, he stopped breathing again.
"I was carrying him in my arms and he just stopped breathing, and he arrested," she said. "Sam dialled 999 and I put him on the dining room table. Sam was talking to the 999 operator and trying CPR."
Paramedics, who arrived at the scene within minutes, were unable to revive him.
The court heard Zac was born in the posterior position – head down but facing the abdomen – which could have caused bruising to his head.
Miss Bradshaw said he appeared "quite red" after his birth. By the morning, she thought he looked a blue-grey colour.
"But I was in love with him, he was perfect to me," she said.
Nursery nurse Karen Derringer, who was working the day Zac died, told the court she noticed the blue-grey colouring and mentioned it to a midwife who was on duty at the time.
That midwife was not present in court to give evidence.
Four other midwives who dealt with Miss Bradshaw and Zac on different occasions before they were discharged told the inquest they did not notice anything out of the ordinary about his breathing or colouring.
Dr Andrew Currie, a neonatologist, also gave evidence.
When asked by the coroner if Zac might have lived had he been transferred to his team when his high temperature was noted, he said: "It's very difficult to answer that.
"That said, if he had come to us and we'd started antibiotics, yes, there is a possibility."
The inquest was told changes had been made following Zac's death. Any baby with a temperature over 38C is now automatically referred to the neonatal team.
Coroner Lydia Brown, who recorded a verdict of death by natural causes, said it was only because of these changes she would not be "raising the matter further" with the hospital.
Following the hearing, Miss Bradshaw said she was pleased the changes had been made.
Jane Porter, head of midwifery at Leicester's hospitals, admitted there were two possible opportunities for Zac to have been referred to neonatology.
"We are incredibly sorry that didn't happen," she said. "We have changed our practice and taken every opportunity to ensure we have learned from what happened."