Baby died as op delayed by 'failure to communicate' with home working doctor

A coroner has issued a warning about NHS consultants working remotely from home after a baby died following a delayed Caesarean section at a scandal-hit maternity unit.

Daisy McCoy's mother visited the hospital reporting reduced and unusual foetal movement, an inquest heard. A scan showed that prior to her birth Daisy had sustained at least one brain injury, possibly due to problems with the umbilical cord or placenta.

However, there was a delay in carrying out the C section operation because of a 'failure to communicate' between staff, including the consultant who was working remotely. Shortly after her birth she was transferred to a larger hospital and then a children's hospice where she passed away just 13 days after the procedure.

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The maternity unit has since closed temporarily due to 'high staff sickness' which the local MP told the House of Commons was partly due to a 'toxic work culture'. Deborah Archer, area coroner for Devon, Plymouth and Torbay, has now warned there is a 'gap' in their policy regarding consultants or midwives attending when understaffing risks patient safety.

She added that she was concerned about the unit reopening later this year if this is not addressed. The inquest heard that Daisy was born via Caesarean section at Yeovil Maternity Unit in Somerset on February 9, 2022.

Her mother had reported with abnormal foetal movement but there was a delay in the operation because of 'failure to communicate' between staff and a lack of training around the significance of this presentation. A scan showed that Daisy had suffered a brain injury due to lack of oxygen or blood flow 'which on the balance of probabilities had occurred before delivery'.

The interruption to blood flow was 'potentially due to a problem with the umbilical cord or placenta'. Her parents were left on their own for an hour with no explanation of how serious the injury was.

The consultant working remotely did not 'fully consider' if she should come into assist because she was unaware of staffing problems on the ward and the unit's guidance did not include asking one to attend if there was an issue outside of the staff's experience or skill set.

Only the registrar knew that the abnormal scan required a call to the consultant within 30 minutes and she did not phone in either leading to a further delay in the procedure. None of the staff checked the criteria for a normal foetal heartbeat and therefore did not escalate the results of the test, the consultant told the inquest if she had been aware of the outcome she would have come on to the ward at that point.

On February 9 Daisy was moved to the larger Southmead Hospital in Bristol before being transferred at some point to a children's hospice in Barnstaple, Devon, where she died on February 22. Ms Archer recorded a narrative conclusion that the 13 day old had died due to an interruption in blood flow to the brain which caused 'significant damage' and peri natal asphyxia before her delivery.

In May 2025 Yeovil Maternity Unit was closed temporarily due to 'high staff sickness' and it is due to re-open November. During a House of Commons session in June Yeovil MP Adam Dance told the chamber absences were caused by partly by 'a lack of support, and toxic work culture, and bullying from management.'

The inquest found that the brain injury was already present when Daisy's mother attended the maternity unit and earlier delivery would not have impacted her chances of survival. However, Ms Archer said the hearing had revealed a 'number of concerns' about procedures at the maternity unit.

In a Prevention of Future Deaths report she said: "The consultant who was working remotely, was not fully aware of the staffing issues on the ward, and this meant that she did not fully consider with all the information whether she should have come onto the unit to assist in person.

"The guidance at the time did not include asking a consultant to attend where there was a presentation outside of the staff’s experience and /or skill set and /or where a significant hypoxic insult was suspected to have already happened. Because of the high acuity on the ward, no one had the time to escalate matters for help or make an accurate note which directly led to no one apart from the registrar knowing that the consultant required a call back on Daisy’s abnormal scan within 30 minutes.

"The consultant failed to telephone the ward back after 30 minutes which led to a further delay in the caesarean being commenced. No professional telephoned the consultant back as they were not aware of the plan to initiate a call

"There was no open discussion between professionals or challenge about whether the initial view of the Registrar that Mrs Mccoy needed a Caesarean was correct." The unnamed consultant said that if she had been made aware of the seriousness of the situation overnight she would have come in.

"Multiple communication issues...resulted in the parents being left on their own for about an hour with no action being taken and the likely seriousness of the insult being left unexplained."

The area coroner warned that further deaths may occur given the lack of training on abnormal foetal movements, absence of policies on escalation of emergencies, and a gap in the policy on consultants attending when the ward is understaffed.

"The matters of concern are as follows," Ms Archer said. A lack of training to recognise unusual foetal movements / compromise and implementation of such training. A lack of familiarity with the processes and polices by midwives to understand foetal compromise.

"A lack of training and policies on rapid escalation of emergency events. A gap in policy to provide for both consultants and or midwives to attend in person where understaffing may lead to patient safety being compromised... A lack of understanding and implementation of the polices that additional staffing in times of high acuity or other emergency situations which if left unaddressed may leave patient safety compromised...

"A lack of adequate communication between different health care professionals on the maternity unit. Her report has been sent to the associate medical director of Musgrove Park in Taunton, the other hospital run by Somerset NHS Foundation Trust and where many mothers from the closed Yeovil unit have been sent, they have until September 30 to respond.