A hospital has admitted that its “substandard care” led to the death of a four-day-old baby.
Sebastian Clark died after developing an infection amid a series of complications during his birth at Kingston Hospital in south-west London.
He was born brain dead and not breathing on 8 March 2017, despite a completely healthy pregnancy.
The hospital said its “learnings from this tragedy” resulted in changes and “improved training guidelines”.
Sebastian’s life support was turned off on 12 March, and he died in his parents’ arms.
His father Justin Clark said it had been “one of the most traumatic experiences”.
Sebastian was resuscitated and moved to St George’s Hospital in Tooting for emergency care, but he was unresponsive to light and sound, the outer cortex of his brain was entirely damaged and there was no chance of recovery, according to the Local Democracy Reporting Service.
A letter from the Kingston Hospital NHS Trust, which the Clarks received last week – almost two years after Sebastian’s death, states: “The treatment and care provided by the trust immediately prior to and during Sebastian’s delivery fell below a standard that you were entitled to expect.
“We recognise that this sub-standard care led to Sebastian’s poor condition at birth and, tragically, his death.”
An inquest into the death concluded earlier.
Recording a narrative verdict at West London Coroner’s Court, HM Coroner Dr Sean Cummings criticised the hospital for “inadequate leadership” and “sequential and individual errors”.
Though “adequately set-up” procedures were in place, Dr Cummings concluded: “There was complacency in managing and defining the situation with the assumption that others on the ward knew about it.”
Dr Cummings said the labour ward was “exceptionally busy”, with other emergency cases taking up medical staff’s time, and a “collective failure to appreciate the developing emergency until it was too late”.
Speaking after the inquest, Tim Deeming of Tees Law, representing the family, said Sebastian’s death had been “entirely avoidable”.
Diana Fleming, consultant and clinical director at Kingston Hospital, said: “We acknowledge and accept the coroner’s findings.
“Our learnings from this tragedy have resulted in the implementation of a number of changes and improved training guidelines to help ensure that this never happens again.
“This tragedy has been most keenly felt by all who work there and our hearts go out the Clark family. I know I speak for them all in saying how very sorry we are.”