HEALTH chiefs at Leighton Hospital have admitted there were "missed opportunities" in the care of a baby who died from a rare pregnancy condition.

Remi Koduah passed away in the early hours of November 23, 2018 hours after his mother, Lauren Hillman, had given birth at the Crewe medical complex [on November 22 that year].

A Warrington inquest heard she underwent an emergency caesarean but the procedures in Leighton's maternity ward were affected by "human error", while staff lacked experience of dealing with Vasa Praevia where umbilical cord blood vessels cross the mother's cervix and fall at risk of rupturing.

Ms Hillman has previously criticised the care administered at the hospital's labour ward.

Mid Cheshire Hospitals Foundation Trust admitted "errors" took place but could not say whether they contributed to the death of baby Remi.

There were early signs of fetal blood loss and a concerning CTG (cardiotocography reading) led to medics opting for a caesarean delivery.

But the surgery was given a lower priority status (category 2, rather than 1), while no consideration was given to administering a blood transfusion when the newly-born's condition deteriorated.

Jenny Butters, head of midwifery at Mid Cheshire Hospitals Foundation Trust, told the hearing that a report into Remi's tragic death highlighted where the hospital could improve.

Cheshire Assistant Coroner Heath Westerman asked the medical chief to explain a series of "missed opportunities".

These included blood not being close at hand on the labour ward as it was kept some way away in the pathology lab.

There had been a lack of recognition of the changes in the baby's heart rate, while the insertion of an umbilical venous catheter (UVC) in theatre was also subject to delay.

Communication between medical staff was also viewed to have been something that could have been better, particularly as the resuscitation room that baby Remi was taken to was located away from the theatre where the surgery was performed.

Ms Butters outlined measures which had been put in place at Leighton since, including locating a blood fridge in the maternity department and more staff training.

Linda Coterrill, a consultant obstetrician, said she had discussed the potential for "human error" in a meeting with Ms Hillman and her partner after the baby's death.

"We talked about human factors, where people do what they do in these situations and how we can often train people to handle these situations better," she said.

"There is nothing in our training that trains us to handle that sort of situation, that comes with experience."

She reported the baby's death to the Cheshire Coroner's office because there was a need to

establish a cause of death. A post-mortem concluded it was as a result of exsanguination (blood loss) because of a Vasa Praevia. Rebecca Kettle, a neonatal consultant who compiled an independent report for the hearing, said that a blood transfusion should have been considered as part of the resuscitation following the C-section, although she said it may not have made a difference to the outcome. The hearing heard how attempts were made to administer fluids, which the neonatal expert agreed with was the correct procedure before "moving up to other options". Asked by the assistant coroner whether it was "inevitable the baby wasn't going to survive?" she replied: "I don't think it was inevitable if it [the resuscitation] had run as per textbook knowledge. "I can't say it was an inevitable death." And the consultant added: "He may have responded had blood been administered within 15 minutes. The use of drugs like adrenalin would have made a difference, but ultimately he needed blood." A consultant, Dr M. Kurre, who was called out on the night found a doctor was attempting to intubate the baby who was then 24 minutes old. His mother had suffered an anaphylactic reaction. She said there had been no mention of a Vasa Praevia and there was no conversation about the need to administer blood, although she told the hearing saline was administered. The baby was "floppy" and there was no heart rate. She said she only became aware of the Vasa Praevia when resuscitation was stopped 22 minutes later. Mr Westerman, the assistant coroner, said that he was satisfied on all the evidence presented to him over the three days of the hearing that Remi's death was not a stillbirth. He said he would reopen the inquest as soon as possible to report his conclusion.