A NEWBORN baby died after his mother was left breastfeeding alone in bed at the Royal Bolton Hospital.
An inquest in Bolton heard that Louie Francis Bradley died in hospital last year due to a combination of factors including an accidental obstruction of the airways following being fed in his mother’s bed.
Assistant coroner John Pollard has now written to Royal Bolton Hospital bosses raising concerns about the advice given by midwives to new mum Ann Bradley, who had given birth to Louie, her first child, the previous day.
He said that it was "extraordinary" that a new mother was left alone in bed with her baby when she was "dog tired" after a long labour.
Ann Bradley, from Croft Gate, Harwood, told the court that she fell asleep while feeding Louie in bed in the early hours of August 27 last year and awoke to find her newborn baby “white and floppy”.
With the baby in her arms she left the ward and to get the attention of a midwife in the corridor.
Doctors attempted to resuscitate Louie, but were unsuccessful.
Mrs Bradley, who works as a teacher, said that she had been advised to put the baby on her bare skin when he was cold and was taught a feeding technique which involved her lying side by side in bed with him.
She said: “They said we could lay on our sides.”
The first-time-mother said that she was never told not to lie in bed while feeding so took him to her bed with her when he became unsettled, fed him for a minute or two and sang to him.
Mrs Bradley told the court that she was feeling “a bit nervous” and was having difficulty breastfeeding so had chosen to stay in hospital for an additional night.
She said: “I was happy to stay. I felt it was a good idea because of how badly the breastfeeding was going.”
Jane Westhead, the midwife who taught Mrs Bradley the feeding technique of lying on her side, said that bed sharing is discouraged and bed safety awareness is discussed.
She said: “We make them aware of the dangers. I don’t know if there’s an actual policy, but that’s what we do.”
The midwife who had worked at Royal Bolton Hospital for nine years at the time of the incident, referred to specific guidelines about bed sharing in her evidence, but the coroner said that advice given had been contradictory.
Mr Pollard said that the technique of lying side by side taught by midwives to help mothers struggling to breastfeed contradicted national advice against ‘co-sleeping’ because mothers are likely to be very tired after giving birth and therefore at risk of falling asleep.
Angela Helleur, a midwife expert and chief nursing officer for Lewisham and Greenwich NHS Trust, told the coroner that it is “common practice” for midwives to advise on breastfeeding in bed.
She said: “We haven’t got much option in terms of where the breastfeeding occurs. The important advice to give is if women feel tired or sleepy to put the baby back in the crib.”
The coroner also expressed concern that breastfeeding in bed would sometimes happen, at a mother’s request, with the curtains drawn around the bed, meaning problems could not be noticed quickly.
He asked Mrs Westhead, whether it was “staff or patients who run the wards”.
She replied: “We can only try to help people. The women don’t want people walking past while they are feeding.”
Mr Pollard also criticised the ward staff for not completing documents and failing to record “significant” details adequately; although Louie’s heart rate, respiratory rate and other key observations were all recorded as normal.
Pathologist Dr Melanie Newbould found that Louie had undiagnosed bronchopneumonia at the time of his death and symptoms of a common cold.
Mr Pollard recorded a narrative conclusion stating: “On the 27th August 2017 Louie Francis Bradley died as a result of a combination of natural and unnatural causes, these being undiagnosed bronchopneumonia and symptoms of a common cold and an accidental obstruction of his airways whilst in bed following a breastfeed.”
The coroner has now written to the Bolton NHS Foundation Trust raising his concerns about breastfeeding advice given by midwives and healthcare assistants as well as the absence of some details from standard records.
The trust must then provide the coroner with a response, including details of the actions taken to address concerns and prevent future deaths, within 56 days.
Following the inquest Val Clare, Head of Midwifery at Bolton NHS Foundation Trust, said: “It is such a tragedy when the unexpected death of a baby takes place. This was a very rare event and we feel for Louie’s family.
“We are a Level Three UNICEF baby friendly initiative accredited unit which is the highest standard for breastfeeding and is a prestigious award, however we always strive for improvement and so, taking into account the coroner’s comments, will review guidance.”
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