HEALTH chiefs say they will make changes to ante-natal care at Leighton Hospital after a coroner's conclusion into the death of a baby.

Remi Koduah died as a result of a rare complication of pregnancy called vasa praevia, passing away on November 23, 2018, less than an hour after he was born.

Cheshire Assistant Coroner Heath Westerman highlighted a "number of missed opportunities" during the resuscitation process, but concluded they would not have contributed to the child's death.

Remi's mother, Lauren Hillman, has criticised the care at the hospital's labour ward, particularly the decision not to undertake a highest priority caesarean section when it became apparent her childbirth was running into problems.

She was left devastated to learn about Remi's death when she came around from her surgery.

Evidence was heard over three days at an inquest held at Warrington Parr Hall in January.

In a narrative conclusion delivered after the hearing reopened on March 14, Mr Westerman stated: "The care and treatment of Remi's mother prior to delivery was appropriate and reasonable, vasa praevia being a rare condition that could not reasonably have been diagnosed before Remi was born.

"Upon discovery at birth there were a number of missed opportunities during resuscitation but it cannot be said that these caused or contributed to Remi's death."

The cause of the baby's death was due to exsanguination due to ruptured vasa praevia.

It is rare condition which occurs when fetal umbilical cord blood vessels cross the cervix opening.

A medic told the hearing in January she had no experience of vasa praevia, that it was only ever reported in 1 in 5,000 births and that in this case it had not presented itself in the way reported in medical text books.

Ms Hillman was induced at the hospital on the evening of Remi's birth. She was concerned about her "blood show" and a decision was made to carry out a caesarean at 11.23pm on the night, although the surgery was a lower priority one (category 2 section, rather than 1).

No consideration was given to administering a blood transfusion when the newly-born's condition deteriorated.

After delivery Remi was "pale and floppy and very ill". He was taken into the resuscitation room, but died in the early hours of November 23, 49 minutes after his birth.

The "missed opportunities" included blood not being close at hand in the resuscitation room – they were kept some way away in the pathology lab - and the failure to recognise changes in the baby's heart rate, while the insertion of an umbilical venous catheter was also delayed.

Communication between medical staff could have been better, it was stated. An independent consultant told the inquest he had never come across a resuscitation room being separate from the operating theatre and stated communication between the two teams was key.

At the hearing in January, Jenny Butters, head of midwifery at Mid Cheshire Hospitals NHS Foundation Trust, said measures had been put in place at Leighton since, including locating a blood fridge in the labour ward and more staff training.

One of the hospital's consultants discussed the potential for "human error" with Ms Hillman and her partner after the baby's death.

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

Making a prevention of future deaths report, the assistant coroner told the hospital trust to take action over potential risks.

Mr Westerman said that while bloods had been moved to the labour ward since the baby's death they are still two minutes from the resuscitation room and "in time-critical moments" may still be too far away.

He also raised concern over the resuscitation area being separate to the operating theatre, which could hamper communications between the obstetric team and the neo-natal team.

The trust has to respond to his report by May 13 this year with details of the action it has taken.

A spokesperson for Mid Cheshire Hospitals NHS Foundation Trust says it carried out a comprehensive investigation following Remi's death.

A spokesperson said: "We would like to offer our sincere condolences to Remi's family for their tragic loss.

"Sadly, Remi died of a rare condition, vasa praevia. While it is not felt that anything would have changed the outcome for Remi, the trust has considered whether there are any changes which can be made to its processes and care offered to patients, to provide improvements.

"These measures are now being implemented, as part of the trust's commitment to learning, patient safety and enhancements to the hospital estate."