There were missed opportunities and failures amounting to neglect over the death of a baby who sustained brain damage during his birth, an inquest has found.

Health chiefs have offered a ’sincere and unreserved’ apology for the tragic death of Max Colley, who lost his battle for life nine months after he was born at the Jane Crookall maternity unit.

Max died in the neonatal unit at Noble’s Hospital on April 11 last year.

He had suffered brain damage in the process of his birth.

Recording a narrative verdict following an inquest into Max’s death, Coroner John Needham said: ’The factual reasons for missed opportunities involved both individual and systemic failures and, in combination, such failures amounted to neglect.’

The cause of Max’s death was established as gastrointestinal and respiratory failure due to severe hypoxic ischaemic encephalopathy.

The Coroner said that despite the known risk of the pregnancy and abnormal features consistently displayed in foetal heart rate monitoring during labour, repeated opportunities were missed to expedite the delivery, most likely through Caesarean section.

Guidelines were not followed as to the need for a consultant obstetrician to be present at the delivery and for there to be the prompt administration of oxytocin to the mother.

During the inquest, extracts from a statement made by Max’s mum Elizabeth were read out in which she highlighted her concerns about a lack of experience among the midwives who dealt with her high risk birth.

She alleged there had been no preparations for her birth at all. She had been told all through her pregnancy that the delivery would take place in theatre but in the event she gave birth in a delivery room.

Mrs Colley claimed no one but her husband Steve was able to see the monitor and he was advising on its readings. ’It was chaos,’ she claimed.

’The emergency buzzer was pulled yet it didn’t seem like an emergency,’ she said. ’It just seemed like disorganised chaos.’

The Coroner found the department has properly carried out its own investigation and was implementing an action plan. Important changes had been made in the organisational structure of the midwifery staff and the emphasis on good communication and team working.

He outlined a list of recommendations which he has forwarded to the Department of Health and Social Care relating to guidelines, equipment testing, record keeping and the making of emergency calls by new staff.

And he added that steps taken by the DHSC to address what went wrong in Max’s case ’should not get forgotten or displaced because of shrinking budgets, cost cutting measures, the replacement of staff or through the simple effluxion of time’.

In a statement, the department said it accepted in their entirety all the Coroner’s comments and recommendations and that those requiring action will be implemented in full.

Health Minister David Ashford said: ’This inquest will have been distressing for the Colley family, and my thoughts are with them and all those affected by Max’s death. I offer sincere condolences on their unimaginable loss.

’A finding of neglect by the Coroner is a matter of serious concern to me and senior colleagues in the department and at Noble’s Hospital.’

The Minister added: ’We recognise that there have been failings, at both individual and organisational level, and have acted and will act to rectify them. We have all learned from this tragic episode, in regard to the safe management of maternity services and the work processes of healthcare staff.’