Tim and Hannah Taylor-Smith, speaking outside Chesterfield Coroner’s Court after the inquest concluded
By Matt Taylor
BBC News, Chesterfield
A baby boy who lived just 14 hours died after “total and complete failures” in his care, an inquest has found.
Zachary Taylor-Smith developed breathing problems and died in November 2022 after what his parents called “appalling treatment” at the Royal Derby Hospital.
The inquest, which concluded on Tuesday, heard neglect had contributed to his death.
The trust that runs the hospital said it was “deeply sorry”.
Image source, Supplied
Zachary’s parents say he was “perfect in every way”
Chesterfield Coroner’s Court was told Zachary was born at 36 weeks after his mother Hannah was induced because of recurrent asthma attacks.
The inquest heard he was initially healthy, but deteriorated.
Midwives previously told the inquest “incorrect” actions were taken and that it was an error that Zachary was not reviewed by the neo-natal team.
University Hospitals of Derby and Burton NHS Foundation Trust (UHDB), which runs the hospital, admitted that had antibiotics been given to Hannah before his birth, or if Zachary had been treated for infection after birth, his death from Group B Strep could have been prevented.
Image source, Tim Taylor-Smith
Mr Taylor-Smith said losing Zachary had been like “living in a real-life horror movie”
Coroner Susan Evans confirmed she would be writing a prevention of future deaths report over Zachary’s death.
She said there were multiple “missed opportunities” to refer Zachary to a neo-natal team during his short life that, on the balance of probabilities, would have prevented his death.
The inquest heard these referrals did not happen, despite warning signs such as a raised respiratory rate and poor feeding.
The coroner said there were “total and complete failures” relating to the provision of basic care, and “gross failings” relating to the fundamental requirements of patient care.
‘Not a learning opportunity’
In a statement after the hearing, Tim and Hannah, from Lichfield in Staffordshire, said: “Zac should have been reviewed by a neonatal doctor at birth and urgently on at least five occasions before he was finally seen when we pressed the crash bell ourselves.
“By then it was too late to save him.”
Tim and Hannah said their son “was not a learning opportunity, nor should he have been a sacrifice made for the greater good”.
They added: “Fourteen is the amount of hours my son lived for. Sixteen is the amount of safety action points the trust had identified prior to the inquest – 1,600 is the amount of issues that the trust had already identified that needed change.
“We think that there needs to be a full review of this country’s maternity services. This is not just happening in one trust or in ‘dark corners’ of the NHS.”
The Taylor-Smiths have called for Donna Ockenden, who is leading the biggest ever investigation into NHS maternity failings in Nottingham, to expand her review to Derby and Burton-upon-Trent.
Since Zachary’s death, changes have been implemented to improve services, the trust said.
This includes a new scoring tool to “quickly and consistently identify any deterioration in newborn babies” and a toolkit, which supports maternity units to build a culture that enables effective clinical escalation.
Garry Marsh, executive chief nurse at the trust, said: “The loss of a baby is devastating and we are sincerely and deeply sorry for the failings in Zachary’s care, which we fully accept.
“We should have provided antibiotics and responded differently to changes in Zachary’s condition and we have been determined to put changes in place.”
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