A Coroner has concluded that a newborn baby who was born prematurely in the early hours of Christmas Day 2023 would likely have survived if missed opportunities in his mother’s care to administer antenatal steroids had not occurred.

At an inquest held last week at Doncaster Coroner’s Court, evidence was heard that baby Sully James Smith was born at Rotherham General Hospital at just 28 weeks and five days’ gestation.

His parents, Michelle and Tom Smith, attended hospital after Michelle began experiencing pains, but Sully sadly died shortly after birth.

In a narrative conclusion handed down on Monday, November 24th, the coroner concluded that opportunities to administer antenatal steroids were missed, which would have improved Sully’s lung function such that he would have likely survived.  

The coroner also made key findings that there was inadequate questioning when Michelle reported symptoms of bleeding and pain at a consultant appointment, and that more robust questioning would have led to admission and the administration of the steroids.

There was also a finding that insufficient weight had been placed on the fact that Michelle was on the Pre-Term Pathway. Michelle had not been informed that she was on the Pre-Term Pathway. The coroner found no evidence that she had been properly informed of the signs of pre-term labour.

During the inquest, The Rotherham NHS Foundation Trust said that since Sully’s death it has made a number of changes to processes including its Pre-Term Pathway, with the introduction of a leaflet for expectant mothers to provide clearer information about the warning signs of preterm labour and when to seek urgent medical help.

Sadie Simpson , an inquest and clinical law specialist at Switalskis, who is supporting Sully’s parents, said on behalf of the family: “This has been an extremely difficult time for Michelle and Tom, who came to the inquest seeking answers about how Sully died.

“They have long believed that more could have been done and that his death may have been prevented, and the coroner’s findings - that there were missed opportunities in Michelle’s care and that Sully could have survived, had they been avoided - is validation that they have been believed after all this time.

“While nothing will ever bring Sully back, it is a relief for the family to finally feel that their concerns have been recognised, and they are grateful for the transparency shown by some of the witnesses during the inquest which has provided a degree of closure and an opportunity to begin healing.

“However, it is also a time of deep sadness as Sully should be two years old on Christmas Day this year.

“Their hope now is that Sully’s legacy will live on and be reflected in the changes made at the Trust, helping to better protect other babies and families in the future.”

Switalskis continues to support the family as they seek accountability and answers through the civil process following the conclusion of the inquest.

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