NHS maternity unit to hold listening events after baby's death linked to remote doctor

A Somerset NHS Foundation Trust maternity unit will hold listening events to improve care after a 13-day-old baby died following a breakdown in communication between ward staff and a consultant who was working from home. The inquest, led by an area coroner, concluded that the infant’s death was caused by an interruption in blood flow to the brain before delivery, resulting in peri-natal asphyxia. Daisy McCoy was born by emergency Caesarean section at Yeovil Maternity Unit in February 2022, but concerns raised at the inquest focused on how delays and miscommunication contributed to the outcome.

Daisy was delivered by Caesarean section at Yeovil Maternity Unit on February 9, 2022. After Daisy’s mother reported reduced and unusual fetal movement, hospital staff failed to escalate the situation promptly, and confusion between medics, including a consultant who was working remotely, delayed the operation. In the ensuing hours, the consultant did not fully consider whether she should come to assist, because she was not aware of broader staffing problems on the ward. The registrar likewise did not contact the consultant within the critical 30-minute window after the abnormal scan, and staff did not check the criteria for a normal fetal heartbeat or escalate the scan results accordingly. As a result, Daisy’s move to a larger regional hospital was delayed, and she was ultimately transferred to a children’s hospice in Barnstaple before dying on February 22.

The coroner, Deborah Archer, said there was a lack of adequate communication between different health care professionals on the maternity unit. She noted a gap in the unit’s policy on whether consultants or midwives should attend when understaffing risks patient safety. The inquest recorded a narrative conclusion that the 13-day-old baby died due to an interruption in blood flow to the brain, reflecting significant brain injury that occurred before delivery.

In response to the findings, Somerset NHS Foundation Trust outlined a series of changes aimed at preventing a recurrence. Chief Executive Peter Lewis said the Trust had refreshed Antenatal Fetal Monitoring Guidelines and conducted additional midwives’ training. It also introduced safety walkarounds and what it described as listening events to gather frontline staff perspectives. The Trust has launched a professional disagreement policy and continues to rely on Freedom to Speak Up Guardians to support staff and conduct regular rounds in the workplace. A culture review diagnostic, led by the national Equity Diversity and Inclusion lead, has been commissioned to assess whether improvements have been embedded across maternity services at Yeovil District Hospital and Musgrove Park Hospital.

Lewis emphasized that the Trust is fully committed to translating learning from Daisy May’s death into safer practice across its maternity services and to maintaining transparency in its ongoing safety program. He said that listening events were held in 2023–24 as part of a broader cultural improvement program and that reopening plans were designed to ensure embedded changes are sustained. While the Trust has not disclosed the exact details of the listening events, officials said they are part of a wider effort to address concerns raised in the Prevention of Future Deaths report and to foster a culture that encourages staff to raise concerns without fear.

The inquest highlighted the importance of timely escalation and cross-disciplinary communication in maternity care. While the case remains a sorrowful reminder of the stakes in obstetric practice, the Trust’s leadership says it is acting decisively to close the gaps identified by the coroner and the family, with a renewed focus on safety, transparency and continuous improvement across its maternity services.