Grieving parents heard that new medical practices could have saved their baby, who died in their arms at just four days old from preventable brain damage caused during labour.
Sebastian Clark was born at Kingston Hospital on March 8 2017, with devastating injuries from which he would never recover.
Failure by midwives to escalate the case and subsequent failure by doctors to expedite the pregnancy, despite knowing that Sebastian’s mother Alison had developed chorioamnionitis, a bacterial infection associated with prolonged labour, led to the tragedy.
An inquest at West London Coroner’s Court that began today (January 16) is exploring how baby Sebastian died.
Mrs Clark told the inquest that medical staff repeatedly told her there was nothing to worry about, and dismissed suggestions of a caesarean birth, despite her concerns about the infection and long labour.
After several hours of being in labour, Sebastian was finally born with the help of forceps – not breathing and with no heartbeat – and was rushed off for resuscitation.
Mrs Clark said: “I didn’t see Sebastian after he was born. I had no clue as to what was going on.
“I was in a state of shock the entire time, and I was very confused.”
The new family was taken to St George’s Hospital in Tooting so Sebastian could have emergency treatment.
Mrs Clark and her husband, Justin, were given books to read to Sebastian, and spent all the time they could with him.
But the couple were told there that their son was brain dead, unable to react to light or hear sounds.
His outer cortex was entirely damaged, and there was no chance of a full recovery.
Holding back tears, Mrs Clark described the moment the couple decided to turn off Sebastian’s life support machine just four days after he was born.
She said: “We felt like we had to do what was right for Sebastian.”
Mr Clark, in a statement read out by Tees Law representative Catherine Cross on his behalf, said: “If we kept Sebastian alive, it would have been for us and not for him.”
He said there was a long time after Sebastian’s birth when neither parent knew what was happening.
After Sebastian was born and rushed off, Mr Clark had to work out for himself what was happening, deducing that a clock he saw was being used to time how long his son had not had a heartbeat.
That clock ran up to 26 minutes.
He said: “I was terrified. I was in a state of panic.
“I was anxiously trying to figure out what was going on.”
Describing the situation, he said: “There was blood – so very much blood. That exact moment will haunt me for the rest of our lives.
“I was fearful for Alison’s and my son’s lives.”
Speaking at the inquest, midwives from Kingston Hospital admitted that new guidelines put in place since Sebastian’s death for dealing with chorioamnionitis would have meant the birth being expedited – reducing the risk of brain damage.
Mrs Clark had been given antibiotics and medical staff believed Sebastian was coping with the infection.
Senior midwives and doctors were aware of her situation, but an “extremely busy” night on the ward meant Dr Kohler-Boureq, who was dealing with Mrs Clark in the latter stages of her labour, “lost track of time” dealing with other emergency cases.
Three women had developed the same infection on the same night, which was very unusual.
Speaking at the inquest, Dr Chorouk Kohler-Boureq agreed that “in the cold light of day” Sebastian’s birth should have been expedited at least an hour before he was finally delivered.
Midwife Jenny Coward, who dealt with Mrs Clark after she was sent from triage, maternity ward sister Anne Banks and midwife Katie Hodder all agreed that new guidelines around chorioamnionitis could have saved Sebastian.
The guidelines, put in place at Kingston Hospital since Sebastian’s tragic death, would have meant birth was expedited sooner – and they would be more wary of the affect the infection could have on babies during labour.
HM Coroner Dr Sean Cummings will deliver his verdict on the case tomorrow (January 17) after the hearing continues.