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A NEWLY-BORN baby died after hospital staff did not realise his mother was in labour, an inquest heard.
Marisa Sanders, of Park Road, Bromley, was admitted to the Princess Royal University Hospital, Farnborough, after her waters broke.
Croydon Coroner’s Court was told Ms Sanders, who was due to have a Caesarean section three days later, was left in a triage room with no buzzer or way of ringing for attention.
She was with her partner Ben, the inquest heard on Tuesday (April 28).
Ms Sanders said: “I was left in a huge puddle of water. I couldn’t walk around.
“When I was asking for help I just did not get it. We were just left in a room with no communication with anyone.”
Medical staff failed to diagnose she was actually in labour and the doctor on duty, Dr Sandra Bynoe, was not called to perform a Caesarean section as she was needed to deal with an emergency in A&E, the inquest was told.
Midwife Janet Unwin admitted Ms Sanders to the hospital at 7.30pm on August 17, 2007.
The midwife told the inquest she took Ms Sanders off an external fetal monitor at 8.20pm as the baby’s heart rate was normal.
The inquest heard Ms Sanders was left until 9.10pm and then again until 10.15pm, when she was seen by an anaesthetist.
Ms Unwin said: “When I was in the room at 10.15 I didn’t feel Marisa was in established labour.
“It was only when I heard screaming at 10.45 I realised Marisa was in full labour.”
Dr Bynoe told the inquest when she saw Ms Sanders the patient was within minutes of giving birth.
The doctor said: “It had surprised me this lady had got to this stage, that she was about to push a baby out and was not on a monitor."
Ms Sanders’ son Thomas was born at around midnight but died on August 19.
A post-mortem examination found his death was due to a lack of oxygen to the brain, the inquest heard.
Consultant obstetrician and gynaecologist Nicholas Hill was part of a Bromley Hospitals' NHS Trust team which looked into what happened.
When asked by coroner Dr Roy Palmer whether there had been a serious failing that night, he said "yes".
Mr Hill said: “When labour was established the diagnosis was not made in time.
“Anyone in labour should have been monitored all the time.
“You would not put a patient who could potentially go into labour into a room without a cord bell.”
Recording a verdict of death by misadventure contributed to by neglect, Dr Palmer said Dr Bynoe was “faced with a crisis” and was in “a situation she should not have had to face, had events earlier in the evening been done differently”.
He said: “In that area there was gross failing to provide basic medical service that contributed significantly to the outcome.”
A spokesman for the trust, now called South London Healthcare, said: "The South London Healthcare NHS Trust are aware of the verdict given by the Coroner on April 28 and wishes to express its profound regret and deepest sympathy for the circumstances leading to the death of Thomas.
"The trust has undertaken a full and extensive review following this incident and the recommendations proposed have now been fully implemented."
Marisa Sanders, of Park Road, Bromley, was admitted to the Princess Royal University Hospital, Farnborough, after her waters broke.
Croydon Coroner’s Court was told Ms Sanders, who was due to have a Caesarean section three days later, was left in a triage room with no buzzer or way of ringing for attention.
She was with her partner Ben, the inquest heard on Tuesday (April 28).
Ms Sanders said: “I was left in a huge puddle of water. I couldn’t walk around.
“When I was asking for help I just did not get it. We were just left in a room with no communication with anyone.”
Medical staff failed to diagnose she was actually in labour and the doctor on duty, Dr Sandra Bynoe, was not called to perform a Caesarean section as she was needed to deal with an emergency in A&E, the inquest was told.
Midwife Janet Unwin admitted Ms Sanders to the hospital at 7.30pm on August 17, 2007.
The midwife told the inquest she took Ms Sanders off an external fetal monitor at 8.20pm as the baby’s heart rate was normal.
The inquest heard Ms Sanders was left until 9.10pm and then again until 10.15pm, when she was seen by an anaesthetist.
Ms Unwin said: “When I was in the room at 10.15 I didn’t feel Marisa was in established labour.
“It was only when I heard screaming at 10.45 I realised Marisa was in full labour.”
Dr Bynoe told the inquest when she saw Ms Sanders the patient was within minutes of giving birth.
The doctor said: “It had surprised me this lady had got to this stage, that she was about to push a baby out and was not on a monitor."
Ms Sanders’ son Thomas was born at around midnight but died on August 19.
A post-mortem examination found his death was due to a lack of oxygen to the brain, the inquest heard.
Consultant obstetrician and gynaecologist Nicholas Hill was part of a Bromley Hospitals' NHS Trust team which looked into what happened.
When asked by coroner Dr Roy Palmer whether there had been a serious failing that night, he said "yes".
Mr Hill said: “When labour was established the diagnosis was not made in time.
“Anyone in labour should have been monitored all the time.
“You would not put a patient who could potentially go into labour into a room without a cord bell.”
Recording a verdict of death by misadventure contributed to by neglect, Dr Palmer said Dr Bynoe was “faced with a crisis” and was in “a situation she should not have had to face, had events earlier in the evening been done differently”.
He said: “In that area there was gross failing to provide basic medical service that contributed significantly to the outcome.”
A spokesman for the trust, now called South London Healthcare, said: "The South London Healthcare NHS Trust are aware of the verdict given by the Coroner on April 28 and wishes to express its profound regret and deepest sympathy for the circumstances leading to the death of Thomas.
"The trust has undertaken a full and extensive review following this incident and the recommendations proposed have now been fully implemented."
