A mother has told an inquest she was 'terrified and alone' after staff at Ysbyty Gwynedd in Bangor failed to wake her for checks before her newborn son died from a brain injury due to oxygen starvation, along with sepsis, in October 2022.
Eve Taylor, 29, had been admitted after her waters broke early at 36 weeks and was identified as having signs of potential infection. She was due to be monitored again later that night, but a midwife decided not to wake her. Taylor awoke hours later and was rushed for an emergency caesarean section. Her son, Sonny Taylor, died three days after being born on 3 October 2022 from a brain injury caused by oxygen starvation and sepsis.
Betsi Cadwaladwr University Health Board has apologised and admitted failings in care, and senior coroner Kate Robertson ruled that the death was preventable. Robertson said that had the missed monitoring taken place and the mother been sent straight to surgery when concerns were raised, the baby would have been delivered earlier. 'Sonny's death would not have occurred at this time,' she said.
In a statement read to the hearing at Caernarfon, Taylor described waking 'feeling an intense fear'. 'Instinctively, I felt that something was wrong and I needed help,' she said. She told a midwife her baby did not appear to be moving as usual, and the team discovered a very low heartbeat. 'Everything seemed rushed and out of control. I felt that the staff were frantic with little organisation,' she said. The hospital moved her to the labour ward rather than directly to an operating theatre, causing a further delay. She described 'panic' with staff arguing. Her son was born in 'poor condition' just after 02:00.
Giving evidence, members of the health board's clinical teams said the case had led to widespread changes and learning for its maternity teams across north Wales, including training, record keeping and decisions on monitoring. Karen Roberts, the head of midwifery nursing, said an audit now showed that monitoring was carried out '100%' of the time when required and a mother would now always be woken if needed.
The hearing also heard that concerns about the death were not referred to the coroner at the time. Robertson said the matter came to her attention following media reports after the health board apologised for its failings. She described it as 'entirely regrettable' that it had taken four years for the inquest to be held, which may have re-opened 'an incredibly traumatic time' for the parents.
Analysis
Why This Matters
- The case highlights critical failures in maternity monitoring, trust in patient safety and the importance of listening to mothers' concerns.
- It raises questions about the referral of hospital deaths to coroners and the timeliness of inquests.
- The health board's admission and the changes promised will be watched for effectiveness across north Wales.
Background
Maternity safety has been a recurring issue in UK health systems, with several high-profile reviews calling for better communication and timely interventions. This case adds to the pattern of missed monitoring leading to preventable deaths.
Key Perspectives
Eve Taylor: Described feeling terrified and alone, and said her son's death could have been prevented if she had been woken for checks and taken straight to surgery.
Betsi Cadwaladwr University Health Board: Has apologised and admitted failings, and said it has implemented changes including training and monitoring audits, with 100% compliance now reported.
Senior Coroner Kate Robertson: Ruled the death preventable and expressed regret over the four-year delay in the inquest.
What to Watch
- The health board's ongoing compliance with its new monitoring protocols will be scrutinised.
- The coroner's criticism of the delay may prompt wider reforms in how hospitals refer deaths to coroners.
Checked
12 claims in this story checked against 1 source: 12 supported.
Show each claim
- SupportedEve Taylor told the inquest she felt “terrified and alone”.BBC Wales: “A mother whose newborn baby died after hospital staff failed to wake her for checks before he was born told an inquest she felt "terrified and alone".”
- SupportedThe coroner ruled Sonny’s death was preventable.BBC Wales: “Sonny Taylor died of a brain injury three days after being born on 3 October 2022, with a coroner saying his death was preventable.”
- SupportedSonny died aged three days.BBC Wales: “Sonny Taylor died aged three days after suffering a severe brain injury caused by lack of oxygen and sepsis in October 2022”
- SupportedA midwife decided not to wake Taylor for monitoring that night.BBC Wales: “She was due to be monitored again later that night, but a midwife decided not to wake her up.”
- SupportedTaylor was admitted after her waters broke early at 36 weeks and she showed signs of potential infection.BBC Wales: “Eve Taylor, 29, was admitted to Ysbyty Gwynedd, Bangor, after her waters broke early at 36 weeks and was identified as having signs of potential infection.”
- SupportedSonny died from a brain injury due to oxygen starvation, along with sepsis.BBC Wales: “The cause of death was a brain injury due to oxygen starvation, along with a sepsis infection, the court was told.”
- SupportedBetsi Cadwaladwr University Health Board apologised and admitted failings in care.BBC Wales: “Betsi Cadwaladwr University Health Board has apologised and admitted failings in care.”
- SupportedThe coroner said that if the missed monitoring had taken place and Taylor had been sent straight to surgery when concerns were raised, Sonny would have been delivered earlier.BBC Wales: “Robertson said had the missed monitoring taken place that evening, and the mother been sent straight to surgery when concerns were raised, the baby would have been delivered earlier.”
- SupportedThe coroner said, “Sonny's death would not have occurred at this time.”BBC Wales: “"Sonny's death would not have occurred at this time," she said.”
- SupportedTaylor said, “Instinctively, I felt that something was wrong and I needed help.”BBC Wales: “"Instinctively, I felt that something was wrong and I needed help," she said.”
- SupportedThe hospital moved Taylor to the labour ward instead of directly to an operating theatre, delaying delivery further.BBC Wales: “The hospital then moved the mother to the labour ward rather than directly to an operating theatre, leading to a further delay in delivering the infant.”
- SupportedKaren Roberts said an audit showed required monitoring happened 100% of the time and mothers would always be woken if needed.BBC Wales: “Karen Roberts, the head of midwifery nursing, said an audit now showed where monitoring of mothers was required, it happened "100%" of the time, and a mother would now always be woken if needed.”