A coroner has issued a serious warning following the death of baby Daisy McCoy at Yeovil Hospital in Somerset, highlighting critical safety concerns about remote working by NHS consultants. Daisy’s death, which occurred just 13 days after a delayed Caesarean section, has sparked calls for urgent review of maternity unit procedures and staffing policies.
During the inquest, it was revealed that Daisy’s mother had reported reduced and abnormal foetal movements prior to delivery. A scan showed Daisy had sustained a brain injury, likely caused by interrupted blood flow due to umbilical cord or placental issues. However, a delay in performing the C-section was attributed to ‘failure to communicate’ among staff and the consulting doctor working remotely from home. Crucially, the consultant was unaware of staffing shortages and the severity of the situation owing to gaps in protocol.
Following birth, Daisy was transferred first to Southmead Hospital in Bristol and then to a children’s hospice in Barnstaple, where she died on February 22, 2022. The inquest concluded that Daisy’s brain injury had occurred before delivery, and while earlier delivery would not have changed her chances of survival, the circumstances revealed significant failings.
Deborah Archer, area coroner for Devon, Plymouth and Torbay, underscored multiple systemic concerns including inadequate training on recognising abnormal foetal movements, poor escalation procedures for emergencies, and an absent policy requiring consultants or midwives to attend in person during critical understaffing.
The maternity unit has since closed temporarily amid high staff sickness and allegations of a ‘toxic work culture’. The coroner cautioned that without improvements, patient safety remains at risk should the unit reopen.
Key issues outlined in the Prevention of Future Deaths report include the lack of clear communication and follow-up protocols, failure to escalate concerns about the scan results, and an overall failure in teamwork. Consultants working remotely were not prompted or required to attend in person during a critical period, largely because guidance did not specify when their physical presence was necessary in understaffed scenarios.
Ms. Archer’s report, sent to Somerset NHS Foundation Trust’s associate medical director, calls for urgent action to address these deficiencies and prevent further tragedies. A response to the coroner’s concerns is due by the end of September.