Baby boy died at just 14 hours old following ‘failures in his basic hospital care'

Zachary Taylor-Smith was born on November 17, 2022 at the Royal Derby Hospital and after a litany of mistakes in the neo-natal department died due to contracting Group Strep B from his mother Hannah.

Coroner Susan Evans, from Chesterfield Coroners' Court, said at Zac's inquest there was “total and complete failures in relation to basic care”.

University Hospitals of Derby and Burton NHS Foundation Trust (UHDB) said it was "deeply sorry" about Zac's death.

Three weeks before the inquest was due to start, the hospital trust admitted that had anti-biotics been given to Hannah, and had earlier treatment for the Group Strep B infection that Zac contracted during his birth been given to him, the death could have been prevented.

The admission was made as part of the medical negligence case that had been brought against it by Zac’s parents Hannah and Tim and their legal team.

Zac’s father Tim Taylor-Smith said: "Zac was perfect in every way; we fell in love with him the moment we laid eyes on him. We were so excited for our other children to meet him, to bring him home knowing that we had the final piece of our puzzle, and he was so loved by all.

"Nothing could have prepared us for what we were to witness, there is no pain like watching your child pass away and being totally helpless to stop it, with the added reality of breaking each of your children’s hearts as they come to understand their sibling is dead. We all struggle to navigate this new life without our child/baby brother, we all miss him so much it physically hurts.

“Zac was not a learning opportunity, nor should he have been a sacrifice made for the greater good. He was a child who was failed by the very people who should have protected, cared for and treated him."

Zac's mother added: "What is particularly hard to come to terms with is the catalogue of errors made in my and Zac’s care. Not one individual recognised that antibiotics should have been given to me during my labour, one simple action that the trust agreed would have made a difference. Midwives also did not recognise that he was deteriorating, which has been accepted was fundamental to their job.

“The hospital staff have referred to ‘individual human error’ but what we heard highlights wider systemic issues. To bring true change the trust needs to take overall responsibility for what happened to Zac, rather than lay the blame on individuals, and make drastic changes to the way it operates its maternity and neonatal services.

“From speaking to other bereaved families, we know that this is not just happening in one trust or in ‘dark corners’ of the NHS. It is widespread and babies are dying unnecessarily. Given that, we are joining the nationwide campaign in calling for a national inquiry into maternity services to shine the light on the truth”

Nicola Wainwright, a partner at JMW Solicitors, is representing the family.

She said: “Hannah and Tim have been through the worst pain imaginable, but they have continued to fight for answers, not just for themselves, but for every other family that has been affected by substandard maternity care at the Royal Derby Hospital.

“The evidence we heard suggests that once Hannah was in hospital for Zac’s delivery, there were negligent failings by nearly every single member of staff who saw her or Zac prior to his collapse.

“Errors were made which were described in evidence as ‘basic’ and ‘obvious’ - important factors that affected the assessment of Zac’s risk of infection were not noted, records were misplaced, a doctor forgot to review and handover Zac, obvious signs of an unwell baby were missed, charts were not completed, and the pathway designed to ensure ill babies are escalated was not followed – not once but repeatedly.

“I cannot imagine how hard it was for Zac’s parents to listen to failure after failure being listed especially when most of them could have been avoided if only a proper system had been in place and national guidance had been followed.”

In November 2023, the Care Quality Commission downgraded Royal Derby Hospital to inadequate. The Healthcare Safety Investigation Branch (HSIB) had carried out an investigation into maternal deaths and injuries at the trust as far back as 2021/2022.