Family's plea after baby Jack's death for ambulance service to learn lessons - The Solihull Observer

Family's plea after baby Jack's death for ambulance service to learn lessons

Solihull Editorial 19th Oct, 2018   0

A NEWBORN baby died after ambulance staff used the wrong technique during delivery because they were unaware of the latest breech delivery guidelines.

Jack Robinson-Morris died on April 18 from a severe brain injury – aged just three days.

His parents Sarah Robinson, 30, and James Morris, 37, are now calling for lessons to be learned following their son’s tragic death.

Sarah was 33 weeks pregnant when she started to develop serious pains and suffered blood loss on April 15 this year.




Her husband called an ambulance at 6.14am – which arrived 27 minutes later.

An ambulance that was closer to the family home in Solihull wasn’t sent because the crew were about to finish their shift.


Jack’s legs, body and left arm were delivered in the back of an ambulance.

Paramedics pulled over and unsuccessfully tried to deliver his head before restarting their journey to Heartlands Hospital.

At hospital he was taken to the neonatal unit where he was found to have suffered a severe brain injury caused by a lack of oxygen when his head was trapped during delivery.

A subsequent internal investigation by West Midlands Ambulance Service NHS Foundation Trust (WMAS) found staff who tried to deliver Jack used the wrong technique and had not seen the latest guidelines.

The last mandatory maternal emergencies training was five years ago.

Sarah said: “It remains incredibly hard to think about what happened to Jack and it is still hard to believe that he is gone.

“Every day is a real struggle. Our arms ache to hold our little boy again. Jack was the most perfect and beautiful little boy who we miss so much.

“It is so difficult not to be angry about what happened, how we feel let down and most importantly how we feel Jack was let down.

“I should be holding my boy in my arms, instead Jack passed away peacefully on my chest. I wouldn’t wish the pain our family is going through on anyone.

“All we can hope for now is that he didn’t die in vain and the ambulance services learns from what happened to him so others don’t have to live with the pain our family is having to endure.”

The report made seven recommendations including all staff undergo training, guidance cards of what to do during complicated pregnancies be introduced and all control staff be reminded of the service’s end of shift policy.

An inquest held in August identified a range of concerns, including the ‘wrong’ ambulance being despatched which delayed Jack’s arrival in hospital.

A WMAS spokesman said: “First and foremost, our thoughts are with the family of baby Jack at what must be an incredibly difficult time.

“The Trust is committed to learning from this tragic case and has already started implementing the seven recommendations that came from the route cause analysis.

“In particular:

· The roll out of further obstetric training will be provided to all frontline operational staff.

· The Trust has re-enforced the policy around the sending of crews at the end of their shift so that patients receive the fastest possible response

· The Trust has appointed a maternity advisor who is working with the clinical team to further develop learning around this area of treatment

· We are urgently looking at ways to provide 24/7 support for staff who come across obstetric emergencies and require advice

“We are determined to spread the learning from this case so that all operational staff can work together to further improve services.”

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