A coroner is seeking reassurances from bosses at Bradford Royal Infirmary about its procedures for dealing with high-risk pregnancies following the death of a twin baby boy.
The infant, Mohammed Esa Rashid, died of multi-organ failure and brain damage three days after a difficult caesarean delivery at the hospital.
During the inquest into Mohammed’s death it was heard the operation and his birth had been delayed due to complications.
His mother, Nafisah Rashid, 26, was admitted to the BRI in June last year after her waters broke early at 34 weeks.
Despite being given steroids to try to develop the unborn twin’s lungs, her labour did develop throughout the day and by the time she was taken for surgery, Mohammed’s head was far down making his delivery difficult, also hampered by scarring from Mrs Rashid's two previous caesareans which meant the incision had to be higher up.
Mohammed was limp as soon as he was born, there were technical difficulties reviving him and he went on to haemorrhage after an attempt to fit him with a canula damaged his umbilical artery which made his condition worse.
Referring to reserving the right to write what is known as Section 28 report for the prevention of future deaths, the Coroner Dr Dominic Bell said he wanted to hear more from the hospital and its obstetrics care delivery.
Recording a narrative verdict he said: “The main focus is not so much on staffing but the planning for Mrs Rashid’s delivery and contingency planning for new emergency arrivals and standards of communication between registrars and consultants.
“It has to be considered that an external review could give me a sense of whether there are issues that need to be addressed more formally.”
Mohammed’s father, Mohammed Rashid, 38, said the family had continued concerns about their son’s tragic death.
Speaking after the inquest, Mr Rashid, of Rhodesway, Bradford, said: “We do not have closure after this inquest at the moment.
“Not a day goes by when I look at my baby son and think there should have be two of you. He is a constant reminder of our other son.
“We thank God that Mustafa survived but we grieve for Mohammed Esa.
“We can’t let what happened to us happen again to anyone else – this is a terrible thing.
“Mohammed was a healthy baby until his delivery and that makes his death hard to bear. If he’d had problems in pregnancy and was a sick baby then we would have had to accept this – but he was not.
“If my wife had been more closely monitored and they had given her a caesarean earlier that day before she went into labour then none of this would have happened and we would have been able to hold our two boys in our arms.”
Mr Rashid said it was known that his wife’s pregnancy was high-risk because of her other two caesareans and because the babies were sharing the same placenta.
He said: “A section had been planned for 36 weeks because they didn’t want her to go into labour – so why did they wait that day and let it happen?
“We know, and the inquest has heard, by the time they finally realised she was in labour the operating theatres were busy with other deliveries so we had to wait our turn – but it was too late.
“We hope the Coroner will decide to take more action to make sure no-one else has to go through what we’ve gone through. There has to be awareness of what has happened to us.”