The tragic death of baby Daisy McCoy at Yeovil Hospital’s maternity unit in Somerset has sparked urgent warnings about the risks of NHS consultants working remotely. A Prevention of Future Deaths report, issued after an inquest into Daisy’s passing, revealed critical communication failures that contributed to a delayed Caesarean section and raised serious concerns about current maternity ward procedures.
Daisy’s mother presented at the hospital with reduced and unusual fetal movements. A scan showed that Daisy had suffered brain injury prior to birth, likely caused by complications with the umbilical cord or placenta. However, the necessary C-section operation was delayed due to breakdowns in communication among staff, including a consultant who was working from home and not fully informed about the staffing shortages on the ward.
Shortly after delivery, Daisy was transferred to a larger hospital and later to a children’s hospice, where she died at just 13 days old. The inquest concluded that the brain injury was pre-existing before admission, and an earlier delivery would not have altered her chances of survival. Yet, the inquiry uncovered numerous procedural deficiencies at the maternity unit.
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The unit has since temporarily closed due to high staff sickness rates, with local MPs citing a “toxic work culture” as a contributing factor. Deborah Archer, area coroner for Devon, Plymouth and Torbay, warned that the maternity unit’s policies fail to address the need for consultants or midwives to attend in person during understaffing, risking patient safety. She expressed concerns about the unit reopening without resolving these issues.
During the inquest, it emerged that communication breakdowns included failure to escalate concerns promptly and insufficient training for staff on recognizing abnormal fetal movements and fetal compromise. The consultant working remotely did not consider attending in person because of lack of awareness of the ward’s high-acuity situation, and existing guidance did not mandate consultant presence when a critical hypoxic insult was suspected.
Only the registrar was aware that the abnormal scan required a consultant callback within 30 minutes, but this did not happen, further delaying the C-section. Additionally, no one challenged the registrar’s initial assessment, and parents were left waiting for an hour without explanation about Daisy’s condition.
The coroner’s Prevention of Future Deaths report emphasized several key concerns: insufficient training on unusual fetal movements, poor familiarity with escalation policies, absent protocols for rapid emergency response, and a policy gap for consultant attendance during critical understaffing. These systemic issues, if unaddressed, may lead to further avoidable harm.
The report has been forwarded to the associate medical director of Musgrove Park Hospital, another facility within the Somerset NHS Foundation Trust, with a required response deadline of September 30.