The inquest into the death of a baby girl at Milton Keynes General Hospital in Buckinghamshire has heard how a shortage of midwives at the hospital contributed to the baby’s death.

BBC News reports that Ebony McCall’s mother Amanda had requested a Caesarean birth because of the pain she was in, but staff had declined to do this, saying it was ‘too risky’.

Miss McCall was 17 years’ old at the time she delivered her baby and had cardiac disease and only one kidney. Staff did not consider that she was a high risk case for cardiac problems, but the inquest heard that when she arrived at the hospital with pains in her stomach, she would have been categorised as high risk. Soon after being admitted to hospital, she went into labour after staff induced her to ease the pains.

During the delivery, baby Ebony’s heartbeat became faint and Miss McCall’s mother, Brenda McCall, said that she triggered an alarm when she saw the baby’s heartbeat ‘spike’ on a monitor during labour.

The baby died shortly after being delivered by emergency Caesarean at 3.21am on 9 May. The inquest into her death heard that she had been starved of oxygen and suffered brain damage.

Mrs McCall said she was later told by staff that had she pushed the alarm button ‘five minutes earlier’ she would have saved her granddaughter.

Mrs McCall added that her daughter’s distress was aggravated by being kept on the labour ward at the hospital for eight days after Ebony’s death.

In 2008, deputy coroner for Milton Keynes Thomas Osborne made recommendations to managers at the same hospital’s maternity unit regarding the care offered. The report followed the death of baby Romy Feast, who died shortly after a Caesarean birth in 2007, after medical staff ‘misinterpreted’ the baby’s cardiotocography.

The Healthcare Commission investigated and Mr Osborne told the inquest into Ebony’s death that many of the HC’s recommendations had not yet been implemented at the hospital.

Mr Osborne said that Ebony’s death was caused by ‘systems failures’ that included ‘overstretched staff’. The baby’s mother had not been seen by a consultant until she was admitted to hospital the day before she delivered her baby.

‘The situation on the labour ward became what has been described to me as “chaotic”, with far too many mums and not enough midwives,’ he said.

Miss McCall’s consultant Anthony Stock said that her care should have been ‘consultant-led’ – and the standard of care had been below that which he would normally expect to be offered ‘for a patient booked in my name’.

The coroner called the shortage of midwives at the hospital’s unit at the time of Ebony’s death ‘nothing short of scandalous’.

The coroner returned a narrative verdict.

The death of baby Ebony McCall has been referred to the Secretary of State for further investigation.

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