A sequence of errors resulted in the tragic loss of a day-old girl at a Welsh maternity unit.  

The coroner determined that the baby could have survived if her mother had been transferred 12 miles to a specialist centre. 

During the inquest in Pontypridd, details emerged about the overlooked opportunities to take the necessary care of Jessica and her baby, Nelly, at the Royal Glamorgan Hospital in South Wales. 

Weighing only 1.13kg (2lb 8oz), Nelly Webb suffered from respiratory distress syndrome, which ultimately led to her passing away. 

South Wales Assistant Coroner, Sarah Richards emphasised that if Jessica had been transferred to Cardiff to give birth, Nelly “would likely have survived,” states The Guardian. 

The coroner confirmed that this was a “systemic failure” and said: “The statement of the baby’s mother made damning reading of a service in disarray.  

There was insufficient attention to the tests, medication and treatment from a team which appeared fragmented with multiple doctors and nurses providing different care plans.” 

Sarah Richards also highlighted that there was a “missed opportunity” due to a delay that took place in inserting a chest drain. Once inserted, the chest drain went to the wrong place. 

After delivering her baby through a caesarean section, Webb, 31, experienced a moment of joy seeing her child after a challenging birth.  

However, this happiness was abruptly shattered as she and Rikki Webb, Nelly’s father, witnessed doctors attempting to resuscitate the newborn. 

According to Jessica, the couple was led to believe that their baby’s death was an unavoidable consequence of her prematurity. 

It came as a shock when they were informed that the care Nelly received was inadequate (and possibly the reason she didn’t survive). 

Cwm Taf Morgannwg University Health Board Chief Executive, Paul Mears, issued an apology to Nelly and her family. He said: 

“Since 2019, we have made significant changes to maternity and neonatal services in our health board.  

This work has been guided by a major improvement programme, overseen by an independent maternity services oversight panel commissioned by Welsh government.” 

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