Coroner rules baby’s death contributed to by neglect of midwives

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Coroner rules baby’s death contributed to by neglect of midwives

A coroner has ruled that the death of a baby who suffered catastrophic brain damage shortly after his birth was contributed to by the neglect of two midwives caring for him at the Royal Bolton Hospital.

The NHS had already admitted that the negligence of midwives responsible for a mother and baby boy at the Royal Bolton Hospital caused the child to suffer catastrophic brain damage and go on to die.

Olly’s mother Emma Clark said: “Olly was so strong and brave throughout his short life. He was such a funny and loving baby who filled our hearts with love. We will always treasure the memories we made with our precious boy.

“Words cannot describe the pain of losing him, it’s there every minute of every day. For this to be avoidable if all the guidelines had been followed compounds everything. We question whether if we’d gone to a different hospital on a different day Olly would still be here.

“We want to raise awareness of the need to listen to parents, to follow the guidelines, which are there for a reason, and to ensure staff are trained in the importance of these issues. Olly was our world and losing him is something we will never fully recover from. Lessons being learned from his death is the only hope we can cling on to.”

Jodie Miller, a partner at law firm JMW specialising in medical negligence who is handling Emma and Michael’s legal case against Bolton NHS Foundation Trust, said: “This is a harrowing case and has taken an unimaginable toll on Emma and Michael. We feel a finding that Olly’s death was contributed to by neglect was the only conclusion that could be reached on the evidence. Olly was born a healthy baby boy and Emma and Michael were full of joy and excitement about the future the family had to look forward to. However all of that was taken away from them when the safety guidelines that exist to prevent this type of incident from occurring were not adhered to. All we can hope is that the action plan put in place by the Trust ensures that no other families have to go through what Emma and Michael have.”

The two midwives treating first time mum Emma and baby Olly following his birth on 13 September 2021 ignored safety guidelines, wrongly leaving him on his mother unobserved while he had his first breastfeed, as one started to repair her tears and the other worked at a computer.

When Emma queried whether Olly was okay, as she was concerned about his breathing, neither midwife came to look, with one simply saying he would move himself if uncomfortable.

As Olly’s feeding slowed, Emma again asked if he was okay. The midwife repairing her tears lifted her head and said he was just asleep and this was normal, without coming to check on Olly.

The midwives should have waited until Olly had been fed and placed in a cot or with his father Michael Vickers before attempting to stitch Emma. Emma also required pain relief in the form of gas and air (Entonox) for the stiches on her grade 2 tears and NHS guidelines state that this should not be given while a mother is holding her baby.

A previous investigation by the Healthcare Safety Investigation Branch had found that the midwives felt under pressure to ensure Olly had a breastfeed within an hour of his birth.

As a result of the failure to monitor Olly, the midwives did not notice when his position changed and his airways became obstructed. When the midwife finished repairing the tears, she took Olly from Emma and found him to be pale and floppy.

The crash team was called and while they could not resuscitate Olly, they managed to get oxygen into him via a ventilator. Olly was taken to the neonatal intensive care unit and remained seriously unwell. An MRI scan of his brain revealed severe damage and Emma and Michael were told that due to the severity he was unlikely to live a long life.

Olly was in hospital for 22 weeks before he was allowed home but tragically died on 6 February 2022 when he was just four months old.


Admission of negligence and HSIB report available on request

Please direct all media enquiries to the contacts below. Please note JMW is managing all media enquiries on behalf of the family.

Kelly Hindle

M: 07921 388 584


Samantha Meakin


Note to Editors

JMW Solicitors LLP is a leading law firm and offers a broad range of legal services to both commercial and private clients.

JMW’s Clinical Negligence team is headed up by leading clinical negligence lawyer, Eddie Jones.

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