Statement on behalf of the Jermyn Family
Tim Goldburn, Partner, spoke today on behalf of Mark and Hayley Jermyn at the end of the inquest into the death of their son Charlie.
He said: “Mark and Hayley are satisfied with the Coroner’s verdict that Charlie died from natural causes contributed to by a sequence of failures in the healthcare system during the first 24 hours of his life, and are understandably devastated by the evidence they have heard over the last three days.
“They believe Charlie was let down by significant system failures at the Royal Cornwall Hospital Trust to train and equip their midwives to take and record a baby’s vital signs and recognise and act on the ‘red flag’ signs of sepsis, including respiratory grunting, which resulted in missed opportunities to save Charlie’s life.
“The expert evidence was that Hayley Jermyn should never have been discharged from the Royal Cornwall Hospital and that on the balance of probabilities Charlie would have survived if he had been born in hospital, or had been admitted by the first two midwives who saw him at home, or after the call to the out of hours emergency helpline if that call had been escalated to a qualified midwife.
“Instead Hayley waited five hours in the busy maternity unit, only to be told she could go home in the early hours of the morning, where baby Charlie arrived suddenly and headfirst into the toilet. Three midwives came to the house in the 30 hours that Charlie lived and although caring and dedicated professionals, none took his vital signs or his temperature until just before he died.
“The midwives gave evidence that they had not seen the Royal Cornwall Hospitals Trust’s clinical guidelines for the diagnosis and treatment of early onset sepsis until the actual inquest, despite these being published in 2013.
“When the family did as they were advised and sought help from an out of hours helpline their call for help was handled by an unqualified maternity support worker who, through no fault of her own, stood no chance of remotely diagnosing vital symptoms of sepsis. That helpline was Charlie’s final safety net, and it failed.
“Mark and Hayley’s sincere wish now is that some good comes from Charlie’s death, and that the Trust’s training and cultural failures highlighted during the inquest are comprehensively addressed.
“The single biggest issue that Mark and Hayley want to highlight to parents and health workers is the symptom of respiratory grunting as a ‘red flag’ sign of sepsis in newborn babies. Poor feeding and sleepiness are other potential warning signs.
“Mark and Hayley are now seeking a personal assurance from Health Secretary Jeremy Hunt that as soon as the Coroner’s recommendations are published about the diagnosis and treatment of sepsis they are implemented in full throughout the country.
“The family would like to thank the Coroner for being so thorough in answering all their questions and extend their thanks to paediatric consultant Dr Katie Mallam and the team at the emergency department at Treliske.
“Charlie Jermyn was a treasured little boy who was loved by many during his short life. Mark and Hayley’s desire is that his life was not in vain and that lessons have been learned to stop any more unnecessary deaths. They now ask that their privacy be respected.”