Support quality, independent, local journalism…that matters

From just £1 a month you can help fund our work – and use our website without adverts. Become a member today

The mother of a four-day-old baby who died at Cwmbran’s Grange Hospital has told an inquest she felt “ignored” by midwives after she reported severe pain and vomiting.

Ceri Lewis was at the hospital for the induced birth of her son, Jac Arthur Lewis, whose care had been consultant-led because the pregnancy was considered high risk due to her having type two diabetes and previously suffering two miscarriages.

Her son had to be resuscitated twice after being delivered by emergency caesarean at 9.29pm on November 1, 2024, and was treated in intensive care.

Gwent area coroner Rose Farmer found that Jac died from natural causes at the hospital on November 5 from perinatal asphyxia – a lack of oxygen to the brain – in a baby with a small placenta.

After hearing more than two days of evidence, Ms Farmer said it was not her role “to decide whether care or treatment could have been improved”, but to consider whether there were “clinical incidents” that required action and whether such steps had been taken.

She said she did not find any “acts or omissions” that contributed to Jac’s death, adding: “Even if I had, I would not be satisfied that causation could be established.”

The coroner said the evidence of consultant paediatric pathologist Dr Andrew Richard Bamber was that the exact cause of the lack of oxygen could not be determined. However, the “very small placenta” had “little reserve” to cope with additional stress and was a “significant contributory factor in Jac’s death”.

When delivering her conclusion, the coroner also said she found Mrs Lewis was not in labour during the earlier hospital appointment.

Ms Farmer said she accepted the evidence of the midwife who was leading Ms Lewis’ care when she attended the hospital at 11.30am on November 1, that she had not been aware Mrs Lewis had vomited. In evidence, the midwife explained what actions she would have taken had she known about vomiting during an induction.

A second midwife, who was leading care during the evening shift, responded after Mrs Lewis reported vomiting. Ms Farmer said she accepted why the midwife had decided to try to manage the mother’s pain before listening for the baby’s heartbeat during an examination shortly before 8pm.

Mrs Lewis was rushed to theatre for the caesarean when the midwife checked for the baby’s heartbeat at 9.13pm.

The coroner said both midwives had made clinical judgements and that their responses to Mrs Lewis’s reports of pain had been documented through observations. Ms Farmer said she did not find the pain to be “clinically significant”, and that both midwives considered it “consistent with induction”.

She also said it was “appropriate” for the second midwife to have asked Ms Lewis to monitor her baby’s movements for ten minutes after she reported being in so much pain she could not tell whether the baby was moving.

Ms Farmer said she did not consider it necessary to issue a Prevention of Future Deaths report. She said she was satisfied with steps taken by Aneurin Bevan University Health Board following its serious incident investigation, which included monitoring a baby’s heart rate during induction in high-risk pregnancies every six hours rather than every 12 hours.

The coroner said she accepted the difficulties Jac’s parents – Mrs Lewis and her husband Matthew – faced in recalling events “at a time of stress”. While she noted that records completed by midwives had not all been written contemporaneously, she accepted that had not always been possible.